LIB R_ A R.Y OF THL U N 1 VLRS ITY Of 1 LLl NOIS C> 1 0 . 0 Un 3 ' I 875 pt. I ^ The person charging this material is re- sponsible for its return on or before the Latest Date stamped below. Theft, mutilation, and underlining of books are reasons for disciplinary action and may result in dismissal from the University. UNIVERSITY OF ILLINOIS LIBRARY AT URBANA-CHAMPAIGN Digitized by the Internet Archive in 2017 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/medicalsurgicalh12unit J c J! r a •u t I s THE MEDICAL AND SLIIGICAL HISTORY OF THE WAR OF THE REBELLION. ( 1861 - 66 .) PREPARED, IN ACCORDANCE WITH ACTS OF CONGRESS, UNDER THE DIRECTION OF Surgeon General JOSEPH K. BARNES, United States Army. AVASlIINaTdN : G O V E R N M E N T P R I N T I N G O F F I C i: . Second Issue, 1875. M E M 0 E A N D U M . Extract from an Act making appropriations for sundry civil expenses of the Government for the fiscal year ending June thirtieth, eighteen hundred and seventy-six, and for other purposes. Approved March 3, 1875. * * * “And the Congressional Printer is hereby authorized to print and bind five thousand additional copies of the Medical and Surgical His- tory of the War of the Rebellion; one thousand of which shall be for the use of the Senate, three thousand for the use of the House of Representa- tives, and one thousand for distribution by the Surgeon General of the Army.” * * * In accordance tvith the foregoing provision of tlie law, a second issue of the First Part of the Medical and Surgical His- tory has been prepared, corresponding, as nearly as practicable, with the first issue. Obvious typogi’aphical errors have been corrected ; but a minute revision of the text has not been attempted, as the time of the officers engaged on the work is fidly occu- pied with the preparation of the second and third parts of tliis large statistical work. JOSEPH K. BAENES, Surgeon General United States Army. War Department, Surgeon General’s Office, April, 1875. 2 TABLE OE CONTENTS 6^0 3 I OF VOLUME II OF PART I OF THE BEING THE E^IJRST SUJKGICAlJL VOLUME. Page. Prefatory, by tlie Surgeon General Ill Introduction by the Editor XIII Chronological Summary of Engagements and Battles XXXIII ON SPECIAL WOUNDS AND INJURIES OF THE HEAD. CHAPTER I. Wounds and Injuries of the Head. Section I. Incised and Punctured Wounds Plate I. Sabre wounds of the Head opp. Incised fractures of the Cranium Plate II. Sabre fracture of the vault of the Cranium opp. Punctured wounds of the Head Bayonet and sword thrusts through Cranium Section II. Miscellaneous Injuries of the Head Railroad Accidents Concussion of the Brain Falls producing Scalp Wounds Cemtusions, Commotions, and Concussions Compound fractures of the Cranium from Falls Contusions, lacerations, and cerebral commotion caused by Blows Head injuries from falling trees Contusions and fractures from kicks by Animals Contusions and fractures by clubs or other Blunt Weapons Head injuries from unspecified Causes Removal of fragments after Cranial Fractures Trephining, eighteen Abstracts of Cases Analytical review of the cases in this Section Table I. Cases of Concussion and Compi’cssion of the Brain Table II. Seat of injury in one hundred and five miscellaneous fractures of the Skull Section III. Gunshot Wounds of the Head Gunshot wounds of the Scalp Table III. Results of seven thousand seven hundred and thirty-nine cases of gunshot wounds of the Scalp. . Abstracts of fifty-four fatal gunshot Scalp Wounds Gunshot scalp wound followed by Encephalitis Erysipelas in gunshot wounds of the Scalp Gangrene in gunshot wounds of the Scalp Hsemonliage in scalp wounds. Abstracts of eleven Ligations of the Temporal and Occipital Tetanus following Scalp wounds by gunshot Pyaemia consecutive to gunshot Scalp Wounds Complications of gunshot Scalp Wounds by intercurrent diseases Summary of cases of gunshot wounds of the Cranial Integuments Table IV. Seat of injury in two thousand four hundred and ninety-thre(! gunshot Scalp Wounds Table V. Nature of missile in four thousand and two Scalp Wounds Balls lodged beneath the Cranial Integuments :! 1 4 16 215 30 32 35 35 37 39 40 42 43 45 47 47 51 55 57 61 66 68 70 70 70 71 75 77 79 80 83 84 8.5 89 90 91 92 f TABLE OF CONTENTS. Section III — Contiimed. Page. Gunshot contusions of the Cranial bones 95 IIscinoiThage and Erysipelas in this class of Wounds — ligation of Temporal 101 Gangrene and Periostitis after gunshot contusions of the Skull 102 Exfoliations following Contusions of the Skull by Balls 103 Plate III. Gunshot Scalp wounds and contusions of the Skull opp. 10.5 Caries after gunshot contusions of the Cranium ■- 106 Persistent pain in the head following gunshot Contusions lOG Vertigo, giddiness, and headache after gunshot contusions of the Skull 107 Chronic Irritahility of the Brain after gunshot contusions of the Skull 109 Meningitis from gunshot contusion of the Skull 110 Cerebritis from the same cause Ill Intracranial Extravasations and abscess after gunshot contusions 112 Paralyses following gunshot contusions of the Skull 113 Loss of vision from gunshot Cranial contusions 115 Deafness from like cause 116 Aphasia, epilepsy, and mental aberration from like cause 118 Pj’asmia and Tetanus after gunshot contusion of the Skull 122 Trephining in cases of this subdivision, sixteen abstracts 123 Kec.apitulatioh and comments on this subdivision 126 Gunshot fractures of the Outer Table alone of the Cranium 128 Recapitulation and criticism of the one hundred and thirty-eight foregoing abstracts 140 Gunshot fractures of the Inner Table alone of the Cranium, — twenty histories 141 Plate IV. Gunshot fractures of the Inner Table opp. 143 Remarks on the bibliography and mechanism of this injury 150 Gunshot fractures of both Tables of the Cranium 159 Linear or capillai’y fissure from gunshot 159 Ligation of the anterior Temporal Artery 160 Fractures of both Tables of the Cranium, without depression 161 Plate V. Gunshot wounds of Sergeant Bemis opp. 162 Balls chipping or splitting on the Cranial bones 163 Balls lodged in the sinuses or diploe 164 Gunshot fractures of the Cranium, without known depression, indefinitely diagnosticated 167 Gunshot depressed fractures of the Skull 167 Survivors of gunshot depressed fractures of the Skull disch.arged disabled 177 Balls splitting on the Cranial bones, with illustrations 180 Recoveries without disability, from depressed gunshot fractures of the Skull 182 Extravasation and intracranial abscess after gunshot 183 Erysipelas, caries, and necrosis following like injuries 185 Exfoliations after depressed gunshot Cranial fractures 187 Remote results of depressed fractures of the Skull by gunshot 189 Gunshot wounds penetrating the Cranium 190 Balls lodged within the Cranial cavity 193 Missiles extracted from within the Cranium 196 Abstracts of thirty-eight fatal penetrating gunshot wounds of the Head 200 Abstracts of five cases of balls lodged within the Skull and unsuspected 204 Perforating gunshot fractures of the Skull 206 Plate VI. Gun.shot fractures of Cranium (chromo-lithograph) opp. 207 Abstracts of partial recovery in fourteen cases of perforation of the Skull by balls 208 Crash or smash — abstracts, with illustrations of cases 212 Removal of fragments after gunshot Cranial fractures 215 Abstracts of seventy-three cases of this subdivision which ended in partial recovery 215 Abstracts of fifty-eight cases of j)cnsioners belonging to this .subdivision 224 Ligation of the superficial Temporal 225 Recoveries with balls lodged within the Brain 234 Foreign bodies removed with bone fragments from within the Skull 236 Abstracts of one hundred and nine cases of this subdivision of presumed recovery not pensioned 240 Ligation of the superficial Temporal 241,244 Fatal cases of gunshot fractures of the Skull treated by elevation or removal of fragments 247 Ilsemori'hage, jwajmia, and othei’ complications of such operations — ligation of Carotid 255 Trephining after gunshot fractures of the Skull 261 Abstracts of fatal cases of this class, with many illustrations 262 Ligation of a Cerebral arteiy 269 Treiduning after gunshot fractures of the Skull — abstracts of cases of recovery, with disabilities 277 Absti’acts of fifteen cases of complete recovery 285 4 TABLE OF CONTENTS. Section III — Continued. rage. Trephining after gunshot fractiu-es of the Skull — abstracts of four cases of patients sent to modified duty. . . 286 Six patients recovering from trephining and exchanged or furloughed 287 Abstracts of thirty-five cases of partial recovery 287 Ligation of supei-ficial Temporal _ 288 Hernia or fungus cerebri 293 Plate VII. Cerebral Hernia after gunshot fracture of the occipital (chromo-lithograph) opp. 295 Ligation of superficial Temporal 298 Counter-stroke fractm-es from gunshot (?) 304 Summary of gunshot injuries of the Head 305 Table VI. Eesults of four thousand three hundred and fifty cases of gunshot injuries of the Cranium 307 Table VIII. Results of nine hundred operations on the Skull 309 Review of the nature and treatment of Head injuries 310 Ligations 313 Ligations of Common Carotid 313 Abstracts of six cases of ligation of Common Carotid 313 Ligation of External Carotid 315 Ligations of Superficial Temporal 315 Scalping, as practiced by North American Indians 315 Foreign Bodies 315 Contre-coup, with bibliographical references 316 Trephining 316 Abstracts of nine cases of trephining 316 Bibliography of trephining 317 Bibliography of fungus cerebri 318 Forms of cranial fracture 318 Repair of cranial fractures and trephine orifices 319 Dr. Holston’s remarks on trephining 320 Bibliography of wounds of the Head 320 CHAPTER II. Wounds and Injuries of the Face. Section I. Incised and Punctured Wounds 321 Sabre wounds of the Face 322 Bayonet wounds of the Face ! 323 Table IX. Results of sixty-four Miscellaneous fractures of the bones of the Face 324 Table X. Results of two hundred and seventy-one lacerations, etc., of the Face 324 Section II. Wunshot Wounds of the Face 325 Gunshot wounds of the Orbital Regions 325 Abstracts of thirty-nine cases of destruction of both Eyes 325 Abstracts of two hundred and fifty-four cases of gunshot injury of one Eye 329 Ligation of Common Carotid 332,339 Table XI. Eesults of one thousand one hundred and ninety gunshot injuries of the Eyes 343 Gunshot fractures of various Facial bones 345 Ligation of Common Carotid 346, 347, 349, 350, 351, 352, 353, 355 Remarks. Ligations of the Carotid in thirteen cases 367 Plate VIII. Wounds of the Face and Neck, Silsbee (chromo-lithograph) opp. 367 Section III. Plastic Operations after Gunshot Wounds of the Face 368 Cases of Blepharoplasty after gunshot wounds 368 Cases of Meloplasty after gunshot wounds 369 Cases of Stomatoplasty after gunshot wounds 370 Cases of Rhinoplasty after gunshot wounds 372 Cases of Cheiloplasty after gunshot wounds 374 Cases of Genioplasty after gunshot wounds 375 Cases of Staphylorraphy after gunshot wounds 378 Review of abstracts cited in this Section 381 Table XII. Results of three thousand three hundred and twelve gunshot fractures of the Face 381 Table XIH. Eesults of four thousand nine hundred and fourteen cases of gunshot flesh wounds of the Face. . 382 Table XIV. Eesults of nine thousand eight hundred and fifteen Face injuries 382 Table XV. Eesults of six hundred and seventy-one Operations on the Face 383 HsemoiThage in gunshot wounds of the Face — ligation of Common Carotid 392, 393 Tabular Statement of thirty-five ligations of the Common Carotid 394 Notes of six ligations of the External Carotid 396 Ligation of the .lugular Vein 397 Excisions of bones of the Face 398 TABI.E OF CONTl'lNTS. CHAPTER III. Wounds and Injukie.s ou tiik Neck. Pago. Section I. Incised and Punctured Wounds and Miscellaneous Inj arks 399 Table XVI. Results of forty-six niiscellaneous injuries of the Neck 400 Section II. Gunshot Wounds of the Neck 401 Plate IX. Wounds of Neck by musket balls (chromo) opp. 403 Balls lodged in the Neck 403 Foreign Bodies extracted in gunshot wounds of Neck 405 Gunshot Wounds of Larynx and Trachea 403 Gunshot wounds of Pharynx and (Esophagus 408 Paralysis after gunshot 'wounds of Cervical Nerves 40S Hemorrhage after gunshot wounds of the Neck j 411 Eiysipelas, gangrene, and other complications 412 Table XVII. Results of four thousand eight hundred and ninety-live cases of gunshot wounds of the Neck. . 414 Section III. Operation on the Neck after Gunshot Wounds 415 Table XVIII. Results of one hundred and thirty-eight Operations on the Neck 415 Operations on the Air-passages 415 Bronchotoiny, Abstracts of six cases r 417 Abstracts of cases of laryngotomy and tracheotomy 418 Ligations of arteries 419 Tabular Statement of fifteen ligations of Carotid 421 Ligations of the Subclavian and minor Trunks 422 CHAPTER IV. Wounds and Injuries of the Spine. Section I. Incised Wounds and Miscellaneous Injuries 425 Incised wounds of the Spine 425 Contusions from falls, blows, etc 426 (For illustration of first case on page 426, see page 450.) Brief abstracts of seventy-nine cases of this nature 427 Section II. Gunshot Wounds of the Spine 430 Gunshot fractures of the Cervical Vertebrae 430 Gunshot fractures of the Dorsal Vertebra) : 433 Gunshot fractures of the Lumbar Vertebra) 441 Tetanic symptoms after gunshot wounds of the Spine 452 Table XIX. Results of six hundred and forty-two cases of gunshot Injury of the Vertebras 452 Remarks on gunshot injuries of the Vertebrie 453 Section III. Operations 455 Table XX. Results of sixty-two operations after gunshot fractures of the Vertebra) 455 Ligations in this class of Injuries 455 Ligations of the Common Carotid 456 Removal of fragments of Vertebra) 457 Removal of balls from Spinal Column 400 Excision of portions of Vertebra) 463 CHAPTER V. Wounds and Injuries of the Chest. Section I. Incised Wounds, Contusions, and Miscellaneous Injuries 466 Sabre wounds of the Chest, — nine cases 463 Bayonet wounds of the Chest, — twenty-nine cases 467 Punctured and Incised wounds of the Chest by various weapons 470 Miscellaneous injui'ies of the Chest 471 Table XXI. Statement of two hundred and ninety-six cases of this division 471 Section II. Gunshot Wounds of the Chest 472 Gunshot flesh wounds of the Chest 472 Foreign Bodies lodged in the Thoracic Parietes 473 Non-peneti-ating injuries of the Chest 473 Internal Injuries without External Wounds of the Chest 476 Penetrating and Perforating Wounds without Fi'acture 478 Gunshot Fractures of the Clavicle 482 Gunshot Fractures of the Scajiula 484 Gunshot Fi’actures of the Sternum 483 Plate X. Penetrating wound of Mediastinum, Betts (chromo-lithograph) opp. 486 Gunshot fractures of the Ribs 488 Complicated wounds of the Lung 491 Gunshot wounds of both Lungs 495 6 TABLE OF CONTENTS. Section II — Continued. Page. Hermetical Sealing in wounds of the Chest 497 Abstracts of twenty-seven cases of Hermetical Sealing resulting favorablj' 499 Abstracts of forty-two cases of Hermetical Sealing resulting fatally 503 Analysis of the foregoing cases 507 Eeport on the subject of Hermetical Sealing by Assistant Surgeon Charles Smart, U. S. A 509 Report on Hermetical Sealing, by Sui'geon H. B. Fowler, T2th New Hampshire Volunteers 511 Eeport on Hermetical Sealing, by Assistant Surgeon G. Derby, U. S. V 511 Eeport on Hermetical Sealing, by Assistant Surgeon B. Howard, U. S. A 512 Hernia of the Lung, or Pneumocele 514 Plate XI. Gunshot wound of Thorax and Abdomen (chromo-lithogi’aph) opp. 515 Plate XII. Gunshot wound of Thorax and Abdomen (chromo-lithograph) opp. 51G Hmmorrhage in wounds of the Chest 519 Wounds of the Aorta and Cavac 519 Wounds of the Anonyma or Brachio-Cephalic 519 Wounds of the Subclavian Artery and Vein 521 Wounds of the Internal Mammary Artery 523 Abstracts of four cases of wounds of Internal Mammary Artery 523 Remarks by Surgeon .1. A. Lidell on Ligation of Internal Mammary Artery 524 Wounds of the Intercostal Arteries 525 Abstracts of eight cases of wounds of Intercostal Arteries 526 Aneurism, axillary, case of 527 Wounds of the Pericardium 528 Abstracts of eight cases of wounds of the Pericardium ' 528 Wounds of the Heart .* 530 Abstracts of six cases of wounds of Heart 530 Cardiac Diseases resulting fi’om wounds 533 Incised wounds of Heart and Pathological specimens 534 Gunshot wounds of the Mediastinum 535 Gunshot wounds of the Thoracic Duct 535 Gunshot wounds of the ffisophagus 535 Gunshot wounds of the Nerves of the Chest 53G Gunshot wounds of the Diaphragm 536 Section III. Operations on the Chest 537 Ligations of the Innominata 537 Ligations of the Subclavian 538 Traumatic aneurism of the Subclavian 541 Remarks on twenty-five abstracts of ligations of the Subclavian 547 Ligations of the Internal Mammary Artery 548 Ligations of the Suprascapular Artery 549 Ligations of the Intercostal Artery, with eight abstracts 550 Remarks and Bibliography 552 Ligations of the Axillary Artery 553 Series of thirteen cases of ligations of the Axillary Artery 553 Ligations of Thoracic branches of the Axillary 556 Excisions of Bones of the Chest 557 Excisions of the Clavicle 557 Abstracts of nine cases of excisions of portions of the Clavicle 558 Excisions of portions of the Scapula 562 Abstracts of four cases of excisions of portions of the Scapula 562 Excisions of portions of the Ribs 566 Abstracts of six cases of excisions of portions of the Ribs 566 Varieties of fractured Ribs 568 Excisions or Trephining of portions of the Sternum 571 Thoracentesis or Paracentesis Thoracis 572 Abstracts of twenty-one cases of Thoracentesis 573 Foreign bodies lodged within the Chest 582 Remarks on the extraction of foreign bodies 589 Table XXII. List of specimens, removed from the Chest during life, contained in the Army Medical Museum . . 594 Abstracts of cases of balls or foreign bodies remaining in the Chest 596 Table XXIII. Statement of four hundred and ninety-four operations for injuries of the Chest 598 Mortality, complications, diagnosis, and treatment of wounds and injuries of the Chest 599 Table XXIV. Statement of twenty thousandsixhundredandsevencasesofwoundsandinjuriesoftheChest.. 599 Table XXV. Statement of wounds of the Chest in the field or primary hosjntal, 1864-65 600 Relative frequency of wounds of the Chest 601 7 TABLE OF CONTENTS. Section III — Continued. Page. Mortality of wounds of the Chest G04 Table XXVI. Statement of eight thousand seven hundred and fifteen cases of penetrating gunshot wounds of the Chest COG Table XXVII. Number of penetrating wounds of the Chest, with ratio of mortality, from various authorities G08 Complications of injuries of the Chest 611 HtEmorrhage in wounds of the Chest 611 Emphysema following penetrating wounds of the Chest 613 Fractures of the bones of the Chest 615 Hernia of the Lung 617 Lodgment of Foreign Bodies 617 Traumatic Pleurisy 617 Traumatic Pneumonia 619 Carditis and Pericarditis 622 Pneumothorax 623 Hydrothorax 624 Hsemothorax 624 Empyema 626 Abscesses in the Lung 628 Plate XIII. Metastatic Abscess in Lung opp. 628 Phthisical tendencies 629 Thoracic Fistula; 630 Collapse of the Lung 631 Contraction of the Chest 633 Secondary Emphysema and Pneumothorax 633 Wounds of the OSsophagus, Thoracic Duct, Nerves, and Diaphragm 634 Wounds of both Lungs 634 Erysipelas and Gangrene ; 634 Tetanus 635 Diagnosis and Prognosis 635 Tromatopnrea .• 635 Htemoptysis 636 Dyspnoea 638 Nervous anxiety 638 Other signs 639 Treatment 642 Local treatment 642 General treatment 642 Index of Eeporters I List of Lithographs 8 LIST OF LITHOGRAPHS. Pi.ATE I, facing p. 4. Sabre Wounds of tue Head. Three fgures: Eight hand, case of Butcher, p. 3; middle, case of Howard, p. 20 ; left hand, cese of Rogers, p. 22. Plate II, facing p. 22. Sabre Fractures of the Vault of the Cranium; case of Strandhurg, p. 22. Two figures: Left hand, external view ; right hand, internal view. Pl.ate III, facing p. 105. Gunshot Scalp Wounds and Contusions of the Skull. Four figures : Eight hand, case of Wheeler, fracture of temporal bone, p. 225; upper middle, case of Beam, contusion of parietal, ]). 121; lower middle, case of Sullivan, fracture of inner table of skull, p. 148 ; left hand, case of Scott, contusion of the skull, p. 105. Plate IV, facing p. 143. Gunshot Contusion of the Cranium, with Fracture of the Inner Table. Four figures: Upper left hand, case of L , p. 143 ; exterior view of Specimen 2313, A. M. M, ; upper right hand, interior view of the same, exhibiting a detached fragment of the lamina vitrea; lower left hand, case of P , p. 142; exterior view of Specimen 1568, A. M. M. ; lower right hand, interior view of the same, exhibiting a depressed fracture of the inner table. Plate V, facing p. 162. Gunshot Wounds of Edson D. Bemis, p. 162; gunshot fracture of both tables of the skull. Plate VI, facing p. 207. GUNSHO'f Fractures of the Cranium. Two figures: Left hand, case of McK , p. 280; right hand, case of Hughes, p. 206. Pl.vte VII, facing p. 295. Gunshot Fracture of the Cranium,— Hernia- Cerebri. Two figures : Case of Kennedy, p. 294. Pl^vte VIII, facing p. 367. Gunshot Wounds of the Face and Neck. Two figures: Left hand, case of Spiegle, wound of neck, p. 402; right hand, case of Silsbee, fracture of facial bones, p. 367. Plate IX, facing p. 402. Wounds of the Neck, by Conoidal Musket Balls. Two figures: Left hand, case of Brown, p. 402 ; right hand, case of Keepers, p. 402. — Plate X, facing p. 486. Penetrating Wound of Mediastinuji ; case of Betts, p. 486. Plate XI, facing p. 515. Gunshot Wound of Thorax and Abdomen, with Hernia of the Lung; case of Captain S , p. 515. Plate XII, fltcing p. 516. Gunshot Wound of Thorax and Abdomen, — wound healed; case of Captain S , p. 515. Plate XIII, facing p. 628. Metastatic Focus in the Lung ; case of S , p. 628. n* 9 I t r\ k. •t I 4 WAR DEPARTMENT, SuRGEOx General’s Office, Novemhei^ 12, 1870. In the first year of the War it became evident that tlie form of Returns of Sick and Wounded, then in use, were insufficient and defective ; and, on May 21, 1862, measures were taken by the then Surgeon General of the Army, Wm. A. Hammond, to secure more detailed and exact reports of sick and wounded, by important modifications in the returns from medical officers. On June 9, 1862, the intention to prepare for publication a Medical and Surgical History of the Rebellion w^as announced to the Medical Staff, in a Circular from the Surgeon General’s Office. On July 1, 1863, a Consolidated Statement of Gunshot Wounds, by Surgeon J. H. Brinton, U. S. Yolimteers, then in charge of the Surgical Records, and Curator of the Army Medical Museum ; and on September 8, 1 863, a Report on Sickness and Mortality of the Army during the first year of the War, prepared by Assistant Surgeon J. J. Woodward, U. S. Army, in charge of the Medical Records, were published by this Office. ^ The necessity for a thorough revision of the Returns of Sick and Wounded becoming apparent, a Medical Board was assembled for this purpose, in July, 1862, and subsequently the following order was promulgated : [CIRCULAR No. 25.] GENERAL ORDERS 1 WAR DEPARTMENT, h Adjutant Geneeal’s Office, No. 355. j Washington, November 4, 1863. Medical Directors of Armies in the field will forward, direct to the Surgeon General, at Washington, duplicates of their reports to their several Commanding Generals, of the killed and wounded, after every engagement. By order of the Secretary of War ; (Signed:) E. D. TOWNSEND, Assistant Adjutant General. Suegeon Geneeal’s Office, Washington, D. C., Nov. 11, 1863. To carry out the intentions of the above order, Medical Directors of Armies in the field will detail suitable officers, who will, under their instructions, collate_ and prepare for transmission to this office, all obtainable statistics and data in connection with past and IV PREFATORY. future operations of those armies, which may he essential or useful in the accurate compila- tion of the Medical and Surgical History of the War. Particular attention is called to the following points: The morale and sanitary condi- tion of the troops; condition and amount of medical and hospital supplies, tents, ambu- lances, etc. ; the points at or near the field where the wounded were attended to ; degree of exposure of wounded to wet, cold, or heat; adequacy of supplies of water, food, stimulants, etc. ; mode of removal of wounded from field to field hospitals ; to what general hospitals the wounded were transferred, by what means and where ; the character and duration of the action, nature of wounds received, etc. When practicable, separate casualty lists will be made of commissioned officers, non-commissioned officers, and privates. The attention of all medical officers is earnestly directed to the importance of this subject; without their cooperation no reliable record can be preserved — the vast experience of the past will remain with individuals, and be lost to the service and the country. J. K. BARNES, Medical Inspector General, Acting Surgeon General. To facilitate the collection and preservation of all important information, medical officers serving with regiments in the field were furnished, in January, 18G4, with a compact and portable Register of Sick and Wounded, and the fol- lowing instructions were issued : [CIRCULAR LETTER.] Surgeon General’s Office, Washington, D. G., January 20, 1864. The Register of Sick and Wounded hitherto in use in the U. S. A. General Hospitals is hereby discontinued. In lieu thereof will be substituted two Registers for each General Hospital, viz: 1. A Register of Sick and Wounded. 2. A Register of Surgical Operations. In the former the appropriate entries will be made whenever a patient is admitted into hospital, and during his subsequent stay therein; and, to assist in the preparation of this Register, a new form of Bed-Cards has been adopted. In the “Register of Surgical Operations,” will be entered, minutely and in detail, the particulars of all operations performed, or treated in hospital. These entries should be made by the medical officers in charge of wards. The above Registers and Bed-Cards are now in the hands of the Medical Purveyors, ready for issue, and you are directed to make immediate requisition for the same, adopting them as soon as received. J. K. BARNES, Acting Surgeon General. To the Surgeon-in-charge of U. S. A. General Hospital. PEEFATORY. V 111 February, 1864, separate Eeports were ordered to be made for Sick and Wounded Eebel Prisoners of War, and for White and Colored Troops, in order to obtain with greater facility the sickness and mortality rates of each. A Classified Eeturii of Wounds and Injuries received in Action, a Eeport of Wounded, and a Eeport of Surgical Operations, were adopted in March, 1864, and distributed with the folio wung circulars : [CIECULAE LETTER.] Surgeon General’s Office, Washington, D. C., March 23, 1864. Medical Directors of Armies in the field will issue the “Classified Return of Wounds and Injuries received in Action,’’ to the Chief Medical Officers of Corps and Divisions, who will see that they are properly distributed. This form, correctly filled up by the Senior Medical Officer of the command engaged, will be transmitted, in duplicate, through the proper channel, to the Medical Director of the Army within three days after every action. The Medical Director of the Army will, as soon as possible, forward to the Surgeon General a Consolidated Return of all Casualties, according to the same form. He will, at the same time, transmit one copy of all Duplicate Returns received from his subordinate Medical Officers. J. K. BARNES, * Acting Surgeon General. [CIRCULAR LETTER.] Sir; Surgeon General’s Office, Washington, D. C., Alarch 28, 1864. You are hereby directed to fill up the accompanying “Report of Wounded’’ and “Report of Surgical Operations’’ for the months of January, February, and March, 1864. The Report of Wounded will consist of an accurate and legible copy of all cases of wounded entered on the Hospital Register during the quarter. The Report of Surgical Operations will consist of a correct copy of the Register of Sur- gical Operations for the same period. A list of wounded remaining under treatment on the 31st December, 1863, in the hos- pital under your charge, and on furlough, is inclosed; you are directed to fill up the column “Result, and Date,’’ opposite the respective names. Additional details for the present quarter, of “Surgical Operations remaining under treatment December 31, 1863,” you will report on appended slips of paper. Blank sets of Reports on Secondary Haemorrhage, Tetanus, and Pyaemia, are also inclosed. These you will fill up in the usual manner. Should no such cases have occurred in the hospital under your charge during the time specified, you will so state in your letter of transmission. VI P R E F A TORY. All of tlie reports above alluded to will, when compiled, be forwarded directly to tlie Acting Surgeon General. By order of the Acting Surgeon General : C. H. CRANE, Surgeon U. S. Army. ]\Iedical Officer in charge of U. S. A. General Hospital. Contemporaneously with the establishment of a more accurate system of Medical and Surgical reports, a pathological collection was commenced, which, under the charge of Surgeon J. H. Brinton, U. S. Volunteers, and Assistant Surgeon J. J. Woodward, U. S. Army, became the basis of the Army Medical Museum, itself, as it now exists, an eloquent and instructive history of the Medi- cine and Surgery of the War, and without which no history could have been com- pletely illustrated. The announcement of this project w^as cordially responded to by Medical Officers throughout the service ; and the list of contributors comprises the names of many most eminent for zeal and ability in the discharge of their duties under the Government, whose honorable records are identified with this work. The following Circular was published more to secure a certain class of speci- mens, than to stimulate the liherality with which most valuable pathological material was being forwarded : [CIRCULAR LETTER.] Surgeon General’s Office, Washington, D. C., June 24, 1864. Medical Officers in charge of Hospitals are directed to diligently collect and preserve for the Army Medical Museum, all pathological surgical specimens which may occur in the hospitals under their charge. The objects which it is desired to collect for the Museum may be thus enumerated : Fractures, compound and simple; fractures of the cranium. Excised portions of bone. Diseased bones and joints. Exfoliations ; especially those occurring in stumps. Specimens illustrative of the structure of stumps, (obliterated arteries, bulbous nerves, rounded bones, etc.) Integumental wounds of entrance and of exit, from both the round and conoidal ball. Wounds of vessels and nerves. Vessels obtained subsequent to ligation, and to secondary hoemorrhage. Wounded viscera. Photographic representations of extraordinary injuries, portraying the results of wounds, operations, or {peculiar amputations. P E E F A T O R Y . VII Models of novel surgical appliances, and photographic views of new plans of dressing. Plaster casts of stumps and amputations, and models of limbs upon which excisions may have been performed. It is not intended to impose on Medical Officers the labor of dissecting and preparing the specimens they may contribute to the Museum. This will be done under the superin- tendence of the Curator. In forwarding such pathological objects as compound fractures, bony specimens, and wet preparations generally, obtained after amputation, operation, or cadaveric examination, all unnecessary soft parts should first be roughly removed. Every specimen should then be wrapped separately in a cloth, so as to preserve all spiculai and. fragments. A small block of wood should be attached, with the name of the patient, the number of the specimen, and the name of the medical officer sending it, inscribed in lead pencil. The inscription will be uninjured by the contact of fluids. The preparation should be then immersed in diluted alcohol or whiskey, contained in a keg or small cask. When a sufficient number of objects shall have accumulated, the cask should be forwarded directly to the Surgeon General’s Office. The expenses of expressage will be defrayed in Washington. The receipt of the keg or package will be duly acknowledged by the Curator of the Museum. In every instance, a corresponding list or history of the cases should, at the same time, be forwarded to this office. In this list the number and nature of every specimen should be clearly specified, and, when possible, its history should be given. The numbers attached to the specimens themselves, and the numbers on the list forwarded should always correspond, and should be accompanied by the name and rank of the medical officer by whom sent. Every specimen will be duly credited in the Catalogue to the medical officer contributing it. J. K. BARNES, Acting Surgeon General. In order to perfect the returns under examination, as far as possible, the fol- lowinof Circular was issued : [CIRCULAR LETTER.] Surgeon General’s Office, Washington, D. C., February 2, 1865. Medical Directors of Armies in the field or of detached commands are instructed lo transmit to this Office copies of all reports in their possession from the Recorders of Division or other Field Hospitals, and in future, copies of such reports will be forwarded to the Sur- geon General within twenty days after every engagement. Medical Directors of Departments will forward to this Office copies of all reports of individual cases of gunshot injury antecedent to the adoption of the present system of regis- tration of wounds, (October 1, 1863,) which are on file in their offices. By order of the Surgeon General ; C. II. CRANE, Surgeon U. S. Army. VIII PEEFATOK.Y. On April 6, 1866, a letter was addressed to each Medical Director, requiring that all Eegisters of Hospitals, Consolidated Eegisters of Soldiers treated, and all information in their possession pertaining to the Sick, Wounded, Discharged, and Dead dnrino- the war, shonld he transferred to this Office. Careful revision of O the material accumulated np to that date, had established its immense value to the civilized world, and it seemed to be demanded that, in justice to humanity, and to the national credit, it should, at once, he made available by publication. By authority of the Secretary of War, Hon. Edwin M. Stanton, Circular No. 6, A Eeport upon the Extent and Nature of the Materials available for the preparation of a Medical and Surgical History of the War, was published, and an edition of seven thousand five hundred copies distributed. Encouraged by the approbation of Secretary Stanton, who took the deepest interest in its success, and aided by his powerful influence, an application was made to Congress, and an appropriation was granted June 8, 1868, for the pur- pose of preparing for publication, under the direction of the Secretary of War, five thousand copies of the First Part of the Medical and Surgical History of the Eebellion, compiled by the Surgeon General, and on March 3, 1869, by a Joint Eesolution of Congress, the number of copies mentioned above was authorized to be printed at the Government Printing Office. Assistant Surgeon J. J. Woodward, U. S. Army, who had been in charge of the Medical Eecords since June 9, 1862, and Assistant Surgeon George A. Otis, U. S. Army, who was assigned to the charge of the Surgical Eecords, Octo- ber 3, 1864, were directed to prepare the work for publication; the zeal and intelligence of these Officers having been already fully established. No work of this character, of equal magnitude, had ever been undertaken ; the Medical and Surgical History of the British Army which served in Turkey and the Crimea during the war against Eussia in 1854, 1855, and 1856, and the Medico-Chirurgical Eeport of Doctor J. C. Chenu upon the Crimean Campaign, published by the French Government in 1865, being the only national publica- tions on military medicine and surgery. It was not considered advisable to follow the classification of either of these works, and a plan was determined on which it is believed will be found adapted to tlm preservation of the great mass of flxcts collected, in a form for convenient study. Through the liberality of the Government, in its beneficent pension laws, it has been found practicable to obtain accurate histories of many thousand wounded or mutilated men for years subsequent to their discharge from service. PREFATOEY. TX The success which has attended this etfort to ascertain the ultimate results of operations or conservative measures, employed in the treatment of the wounded in the late war, is largely owing to the cordial cooperation of the Surgeons Gen- eral and Adjutants General of States, the Examining Surgeons of the Pension Bureau, and very many private Physicians throughout the country. As in the official returns of the casualties of the French and English Armies in the Crimean War, the cases were dropped when the men were invalided, pensioned, or dis- charged from service, this information was considered peculiarly desirable. In carrying out the intentions of Congress, it has been my earnest endeavor to make this Medical and Surgical History of the War, not only a contribution to science, hut an enduring monument to the self-sacrificing zeal and professional ability of the Volunteer and Begular Medical Staff, and the unparalleled liberality of our Government, which provided so amply for the care of its sick and wounded soldiers. To the Medical Officers connected more immediately with this work, for most cordial assistance and unceasing industry ; to those who, at the close of the war, returned to civil life ; to the members of the Medical Staff of the Army and Officers of the various Bureaux of the War Department, for the courtesy and promptness with which requests for information have invariably been responded to, I am deeply indebted. My thanks, and those of every possessor of these volumes, are especially due to the Superintendents of the Government Printing Office, and their skilled assistants, who have spared no pains in making the typography and execution of this pubhcation worthy of the Government and the Nation it represents. JOSEPH K. BAENES, Surgeon General U. S. Army. 2 * « I > . « • • I k C ’ r ■J . 1 , THE MEDICAL AND SLEGICAL HISTORY OF THE WAR OF THE REBELLION. PART r. VOLUME II. SURGICAL HISTORY. Prepared, under the direction of JOSEPH K. BARNES, Surgeon General United States Army, By GEORGE A. OTIS, Assistant Surgeon United States Army. (SECOND FIVE THOUSAND.) I ■« INTRODUCTION. In the preparation of 1116 surgical portion of the Medical and Surgical History of the War of the Rebellion, it was at first proposed to treat of the surgery in connection with the military operations of the several battles and campaigns. Surgeon John H. Brinton, U. S. V., originally assigned to the task,* prosecuted his work on this plan. After giving a general account of a campaign, enumerating the troops engaged, the mode of transporting the injured, and the available hospital accommodations, the wounds and operations of each engagement were discussed, the reports of medical directors, and all other reliable sources of information being brought into requisition. Among these were observations personally made in the base and field hospitals of the armies of the Potomac and of the West, after the great battles, where much valuable surgical material was collected, including admirable illustrations of the graver injuries, pathological specimens, and a series of excellent surgical drawings. ’ Such a plan was adapted to the outset of the War, when its extent and pro- tracted duration was anticipated by no one ; but toward the close of the year 1864, it became apparent that a plan susceptible of wider generalization must be adopted, for the clerical force then at the disposition of the Surgeon General was hardly sufficient to classify the immense returns from the hospitals and battle-fields of the Army of the Potomac alone. During that year there were no less than two thousand slvirmishes, actions, or battles, and to have given a correct analysis of the casualties from the returns from the field and base hospitals would have been impossible. For the number of wounded received at the Wash- ington hospitals alone, during the quarter ending June 30th, 1864, was over thirty thousand, and the total number of wounded reported by all the general hospitals exceeded eighty thousand. Therefore, in 1865, it was suggested, in the report of materials available for a Surgical HTstory of the War,f that the wounds and operations be classified according to regions, — ■ important cases being described at length, and brief abstracts or numerical tabular state- ments being furnished of the less important cases. It was decided that this plan should be adopted, and that the reports of medical direct- ors and others, relating to the field service, should be published as “appended documents” to the Medical and Surgical History. They are hound in Volume I, Part I. In the preliminary surgical report in Circular No. 6, S. G. 0., 1865, the materials available for a complete surgical history are fully described, and in the introduction to the medical volume of Part I, of the Medical and Surgical History, the form of the monthly report of sick and wounded required of each hospital, post, regiment, or detachment at the beginning of the war, and the various modifications made in the blanks during its progress are clearly explained, and the causes of discrepancies and probabilities of errors plainly pointed out. It remains only to advert briefly to some other sources of information of an exclusively surgical nature. Though, from the beginning, it had been customary for medi- * See Circular No. 5, Surgeon General's OfiBcc, June 9th, 1802. t Circular 6, S. G. O., 1805. XIV INTEODUCTION. cal directors to forward to the Surgeon General lists of the killed and wounded after each engagement, it was not until late in 1863,* that these returns were made obligatory and rigorously exacted. They were of the greatest utility in furnishing the means of tracing patients to base or general hospitals, where their histories were more fully detailed. The lists were on forms, twelve by sixteen inches, ruled as follows : List of Wounded in the Brigade^ _Divisionj Corps^ Army of , at the Battle of 071 the day of , 186 . D 'A Najies. o Regimext. Corps. Injury. Treatment. Result AND Date. Remarks. Surname. Christian name. Missile or Weapon. Seat of. Nature of (slight or severe.) Note I. — TWs List will be made with the strictest accuracy, and will be transmitted bj’ the Medical Directors of Corps to the Medical Director of the Army, within seven days after an en"a{?ement. The names of all men treated in the Hospital will be entered upon this List. When men are transferred to or from other Division Hospitals, the fact of the transfer and the date will be noted in the “Remarks.” Note II. — It is enjoined upon Medical Officers to state in the column “Nature of Injury,” whether the wound is a flesh-wound or a fracture or a penetrating wound of the cavity. Surgeon in Chief Division j Corps, The pocket field register, five and one-half by eight and one-fourth inches, referred to by the Surgeon General on page IV of his prefatory remarks, as issued to regimental sur- geons, answered a like useful purpose. It was ruled as below. Only about five hundred were transmitted to the Surgeon General’s Office at the close of the war. Register and PrescAption Booh of,, Regiment No. Name. Rank. Reg't. Cojrp. Disease. Ln Hospital OR Quarters. Prescription and Resiakks. ' *.See Gen'EKAL OupKHS No. 355, liar Department, A • I— I -+^ c3 Ph -4-^ CQ o c5 o p s-i CO CD '°p a ?H cS .!^ a ^ o tS ^ a'C g g B ^ K 3 5 •JiaflKHK IVXIcTSOII IN TKOD UCTION. XVII That a continuous record might be kept, the names and military descriptions of all sur- gical patients remaining under treatment at the conclusion of the quarter, were copied, at the Surgeon General’s Office, from the quarterly reports of wounds and of operations, upon folio blanks of the form following. These lists were mailed to the hospitals, where the progress or result of each case was recorded, and the paper thence returned with the suc- ceeding quarterly reports : List of Wounded remaining under treatment at U. S. A. Hospital, at the beginning of the quarter which ends , 186 [Note. — T his form, with the cohunn “Result and Date ” properly filled up, will be returned by the Medical Officer in charge to the Surgeon General, U. S. A.] Hospital NUMUEI!. NAME. CO. REGIMENT. DIAGNOSIS. RESULT AND DATE. Prior to the adoption of the quarterly reports of wounded and of operations, patients were supplied with descriptive lists, on foolscap, ruled and lettered in the following form. Except in cases of transfer, these were not filled out with much fidelity, but occasionally they furnished important facts and even histories of grave cases that would otherwise have escaped notice : MEDICAL DESCRIPTIVE LIST. Ward , Bed Name Disease or Injury, Result, (Name of attending Medical Officer.) General Hospital at _ , Ranlc , Co. , Regiment Date of < Admission, Return to duty, cured, Furlough, Discharge from service, Transfer to another Hospital, Death, Note. — W hen a patient is first receiTCd into a General Hospital, the entries on this Descriptive List will be commenced. All important changes in his condition will be noted on it (in ink), from time to time, by the Surgeon in charge of the Ward. When the patient has been wounded, the date and character of the wound will be stated, the nature of the operation (if any), and, above all, the result. In case of transfer, this list will be sent, through the officer in charge of the transportation, or failing one, by mail, to the Surgeon in charge of the Hospital receiving the patient. When this medical history shall have been completed, by the cure, discharge, furlough, or death of the patient, it will, with the treatment and result carefully noted, be transmitted directly to the Surgeon General. Date. Tkeatmeat. Diet. Remarks as to condition of patient, &c. There was the following endorsement : Name of Hospital, Name of Patient, Disease or Injury, Result, Date of Transmission, 3 * XVIII INTROJIUCTION. The entries on bed-cards sometimes supplied missing links, in tracing the chain of evi- dence of important cases. These cards were printed on thick paper or card-board, five and one-half by three and one-half Inches, and were classified and transmitted to the Surgeon General’s Office when the hospital closed. The form of the cards used (face and back) may be seen below : Form of Bed-card used in the United States General Hospitals. HOSPITAL NUMBER Name Age , Nativity Married or Single Residence Post-Office address of wife or nearest relative, Rank , Co. , Regiment IVhen admitted From what source Diagnosis : — (In surgical cases state explicitly seat and character of wound or injur}-.) On what occasion wounded Date Nature of m issile or weapon TREATMENT. [IIKRE NOTE IMPORTANT COMPLICATIONS AND ALL OPERATIONS.] RESULT AND DATE. It was anticipated that much information would be derived from the discharge papers for physical disability, but, after a laborious examination, it was found that the surgical cer- tificates were generally brief and vague, and comparatively useless for statistical purposes. The rolls of soldiers transferred to the Invalid Corps were searched with nearly the same result, the surgical memoranda being practically worthless. The objects in view in the formation of this corps were jierverted, many sound, healthy soldiers being transferred to suit the convenience of officers who took them from the ranks to serve as clerks, cooks, nurses, or other attendants, and it became necessary that the corps should be reorganized. This was effected by discharging and pensioning the utterly disabled men, and dividing the remainder, according to the extent of their disabilities, into two battalions of “Veteran Pieserve Corps,” the second battalion being composed largely of men maimed by the loss of a limb. The entries were useless in a surgical point of view, being as concise as: “ampu- tation,” or “amputated leg,” or “excised elbow.” When, in 1866, four regiments* of Vet- eran Reserves were incorporated with the Regular Army, the Surgeon General instructed the examining surgeons, at the recruiting stations, to take careful notes of all extraordinary cases of injury or mutilation presented to them. Through this channel much valuable material was obtained. The numerous survivors of grave wounds and mutilations who have visited Washing- ton to prosecute their pension claims, or to solicit places under Government, or to obtain orders for artificial limbs, generally visit the Army Medical Museum, and the writer has thus had the opportunity of personally examining such cases, and of preparing six quarto volumes of photographs of the more remarkable examples.*}* The Museum also possesses * The 42d, 43d, 44th, and 45th United States Infantry. t Sets of tltese volumes have been distributed, by the Surgeon General’s direction, to the principal medical colleges and learned societies of the country. T NTRODITCTION. XIX fourteen quarto volumes of contributed pliotographs, and a vast number of card-size pictui es, indexed and classified, but not bound. The formal reports of medical directors of armies give a general view of the opera- tions of the Medical Department. For the Army of the Potomac, the reports of Medical Directors King, Tripler, Letterman, and McParlin furnish a connected narrative of the serv- ices rendered by the medical staff. For the western armies, the reports of Medical Direct- ors McDougall, Murray, Mills, Cooper, Swift, Perin, Moore, J. H. Brinton, and Hewit afford similar information. These papers depict an outline of the surgery of the war, and place in evidence the immensity of the task that devolved on the Medical Department, and vindi- cate its achievements, in showing the extent of the succor given to the wounded in de- spite of almost incredible obstacles. Besides these authoritative documents, there are on file in the office, to serve as supplementary reports, individual narratives of observations in active service from each member of the regular or volunteer medical staff. Such por- tions of these reports as appeared to possess historical interest are printed in the Appendix to Part I of this work. hluch important and otherwise unattainable information regarding the ulterior conse- quences of the more important and rare injuries has been collected by private correspond- ence with invalided soldiers and their surgical advisers. More than fifteen hundred cases have been examined in this way.^ Several interesting cases and valuable pathological specimens have been contributed by officers of the medical staff of the United States Navy.^ Many of the former medical officers of the Confederate army have aided in the prose- cution of the work by contributing histories of cases, pathological specimens, statistical data, and facts concerning the terminations of the major injuries and operations. It may be per- mitted to express the hope that the claims of these gentlemen, with those of all others who have contributed largely to the materials available for their preparation, will be favorably considered by Congress, in the distribution of these volumes.^ But the principal sources from which the remote results of wounds, injuries, and opera- tions were ascertained, were the reports of pension examiners, and communications from the surgeons general and adjutants general of States. The cordiality and zeal with which all of these officials have responded to every enquiry of this office, and facilitated its researches in many ways, have been acknowledged, but cannot be too highly appreciated.^ * Not infrequently the addresses of sunTvors of rare injuries or operations were unknown, and resource was liad to various expedients by advertising in the secular press and elsewhere. Thus the ultimate results of Dr. Head's case of successful excision at tlie knee-joint and Dr. Compton's primarj’ amputation at the hip-joint were determined. 2 Sec Specs. 5884 and 2273, Sect. I, Army Medical Mtisemn, for cases cf coxo-femoral exarticulations by Surgeon W. E. Taylor, U. S. N., and Surgeon A. C. Corgas, U. S. N., and Spec. 5662, presented by Passed Assistant Surgeon R. J. Tryon, U. S. N., for a fracture of the leg jiroduccd by a torpedo explosion. Dr. Trj'on also ct.mmunicated a number (if surgical memoranda from his private case-book. * Among the large number who have thus contributed, I may enumerate the following, with whom I had the pleasure of personal correspondence: Dr. Thomas Williams, formerly medical director of the Anny of Northern Virginia; Professor HUNTEii JIcGLOUih late medical director of (Icncral Jackson's Corps ; Dr. J. P. Gilmokk, late chief medical officer of General McLaws’s Division of General Longsfreet's (’orps; Dr. John D. Jackso.v, late surgeon P. A. C. S.; Dr. W. W. Comptox, of Holly Springs, Mississippi ; Dr. Clalide II. MASTIN', late medical inspector C. S. A.; Dr. J. F. GRANT, of Pulaski. Tennessee; Dr. W. L. 15AYLOR, of Petersburg, Virginia; Professor J. J. CiiisOLM, of Baltimore, Maryland; Professor Miles, of Baltimore, Maryland: Dr. 11. D. THOMAS, of Richmond, Virginia; Dr. T. G. RiCiiAUD.sOX, of New Orleans; Dr. J. R. BuiST, of Nashville, Tennessee; Dr. A. C. CUVMES, Fort Browder, Alabama; Dr. A. M. Fauxtlerov, of Hunton, Virginia. Where all cooperated cheerfully, according to the opportunities at their command, it is hoped that it may not be deemed invidious to advert particularly to the pains taken by the successive adjutants general of New York and Pennsylvania to trace the histories of invalids unaccounted for on the national records, and to the kind and constant interest shown in the work by Surgeon General W. J. Dale, of Massachusetts, Surgeon General James K. Pomfret, of New York, formerly surgeon of the 7th New York Artillery, and Surgeon General II. II. Smith, of Pennsylvania. Among the pension examiners, of whom many, fortunately for all concerned, were formerly military surgeons, cordial and discriminating assistance has been received from Drs. F. Salter and T. B. Hood, late stalf-simgeons of volunteers, and Dr. A. L. Lowell; from Dr. A. N. Dougherty, late medical director of the Second Corps : from Drs. G. Derby and S. A. Green, of Boston, Dr.s. H. S. Hewit and George Suckley, of New York, late medical directors of tlie Armies of the Ohio and of the James ; from Drs. George C. Ilarlin and H. K. Goodman, of Philadelphia, Prof. F. Bacon, of New Haven, Dr. D. W. Maull, of Wilmington, Drs. T. W. Wislinrt, and G. McCook, of Pittsburg, Dr. II. M, Dean, of I^itchfield, Dr. J. M. Woodworth, late medic.-il inspector of the Army of the Tennessee, Dr. C. S. Wood, of New York, Dr. T. H. Squire, of Elmira, and many others. XX INTRODUCTION. It is unnecessary to enlarge on the great facilities afforded hy the unrivalled collections of the Army Medical Museum.^ It is sufficient to say that it possesses over six thousand surgical preparations, affording illustrations of the primary, intermediary, and remote effects of most of the injuries incident to war, and of the morbid processes, which characterize the different stages of most surgical diseases. It contains, also, a collection of weapons and projectiles, a good series of dissections and studies in topographical anatomy, many wax, plaster, leather, and papier-machd casts of the results of operations, and a large number of specimens, models, and drawings illustrating the materia chirurgica and methods of trans- jDort for the wounded. The various manuals and systematic treatises on military surgery and the numerous contributions on the subject published in periodicals during the war, or since its conclusion, have been carefully and often advantageously consulted.^ Another and a very valuable store of information was added, at the close of the war, in the shape of portions of the Confederate Hospital Eecords. These comprised the con- solidated monthly reports of sick and wounded of the Army of Northern Virginia from July 21st, 1861, to May 3d, 1863 ; two hundred and thirty-three hospital registers ; one hundred and sixty case books ; fifty-two diet and prescription books ; seventy-eight order and letter books, and a number of records of clothing issues and other administrative matters. There were also many books of miscellaneous memoranda,* * and a large collection of monthly and quarterly sick reports, discharge papers, muster and pay-rolls, reports of boards of survey, and the like. ^Of csteological preparations of the results of injuries of the head there are 422 specimens; of wet preparations of lesions of the soft parts, casts of plastic operations, etc., 72 specimens ; cf specimens of injuries and diseases of the spine, 128 ; of preparations of all kinds illustrating wounds and injuries of the chest, there are 210 specimens, and of similar preparations belonging to the abdomen, 82; 1,340 specimens illustrate the amputations and 1,200 specimens the excisions, and there are 1,570 preparations of the different degrees of destruction or repair in the injuries of the bones cf the extremities. * Among them an exceedingly interesting yolume containing the correspondence between a benevolent society, entitled the “Association for the Hclief of Maimed Soldiers, ’ cf which Dr. W. A. Carrington, C. S. A., ■was secretary', and a cooperative association in England, presided over by Lord Wharncliffe. From this volume the details of many cases of amputations and excisions have been gleaned, which will appear in their proper places in this History. * Among the American books and papers on military surgerjq that have been consulted, the following may be enumerated. The foreign medico- military bibliography will be referred to further on: JOXES, J., Plain, Concise, Practical Remarlcs on the Treatment of Wounds and Fractures, with an Appendix on Camp and Military Hospitals, Principally designed for the use of young Military and Naval Surgeons in North America, Philadelphia, 177G; Rush, Medical Inquiries and Observations, Philadelphia, 1793-94, Vol. I of his works; Barton, A Treatise on Marine, Flying, and Military Hospitals, Philadelphia, 1817 ; Mann, J., Medical Sketches of Campaigns, 1812-1814, Dedham, 1816; Parsons, U., Prize Dissertations on Inf animation of the Periosteum, Eneuresis Irritata, Cutaneous Diseases, Cancer of the Breast, Malaria, 2d ed.. Providence, 1849; PORTER, J. B., Medical and Surgical Notes of Campaigns in the War with Mexico, during the years 1845, 1846, 1847, and 1848, Am. Jour. Med. Sci., Vols. XXIII. XXIV, XXV, and XXVI, January, 1852, to January, 1853; WRIGHT, J. J. B., On a Gunshot Perforation of the Chest (in Dr. F. II. Hamilton’s Pract. Treat, on Mil. Surg., 1861, p. 157) ; Jarvis, N. S., N. Y. Jour, of Med., 1847, Vol. VIII, p. 151 ; Hulsk, G. W., Gunshot Wound of the Head, Kew York Jour, of Med. and Surg., January', 1841 ; Henderson, T., Topography of Madison Barracks, Am. Jour. Med. Sci., April,' 1841; Vol. I, N. S., p. 337; Lawson, T., Meteorological Register for the years 1826 to 1830, inclusive, From observations made hy the surgeons of the army and others at the military post of the U. S. Army, To which is appended the Meteorological Register for the years 1822 to 1825, inclusive, by Joseph Lovell, Philadelphia, 1840 ; FORRY, S., Statistical Researches on Pulmonary and Rheumatic Diseases, based on the Records of the Medical Department, U. S. Army, Am. Jour. lilcd. Sci., Vol. I, N. S., 1841, p. 13 ; Trii*ler, C. S., Manual for the Medical Officer of the Army of the United States, Part I, Cincinnati, 1858 ; Tripler. C. S., and BLACK- MAN, G. C., Handbook for the MUitary Surgeon, Cincinnati, 1861 ; ClllSOLM, J. J., A Manual of Military Surgery, for the use of Surgeons in the Confederate States Army, 3d ed., Colmnbia, 1864 ; Hamilton, F. II., A Practical Treatise on Military Surgery, New York, 1864 ; and A Treatise on Military Surgery and Hygiene, New York, 1865; GROSS, S. D,, A Manual of Military Surgery, Philadelphia, 1861 ; Warren, E., An Epitome of Practical Surgery for Field and Hospital, Richmond, 1863 ; Manual of Military Surgery, Prepared for the use of the Confederate States Army, hy order of the Surgeon General, Richmond, 1863; Smith, S., Bandbookof Surgical Operations, 3d ed., New York, 1862; Smith. S., Statistics of the Operation of Amputation at the Hip-Joint, in New York Journal of Medicine, Sept., 1852, p. 93; COOLIDGE, R. IL, Statistical Report on the Sickness and Mortality in the Army of the U nited States, Compiled from the Records of the Surgeon General's Office, Embracing a period of sixteen years, from January, 1839-55, Washington, 1856 ; the same, Embracing a period of five years, from January, 1855-60, Washington, 1860 ; WARREN, J. 51., Surgical Observations, with Cases and Opera- tions, Boston, 1867 ; Nott, J. C., Contributions to Bone and Nerve Surgery, Philadelphia, 1866 ; SCHUPPERT, 51., A Treatise on Gunshot Wounds, Written for and dedicated to the Surgeons of the Confederate States Army, New Orleans, 1861 ; Andrews, E., Complete Record of the battles fought near Vicksburg, December, 1862, Chicago, 1863; Bartiioi.OW, R., A Manual of Instruction for enlisting and discharging soldiers, Philadelphia, 1864 ; Bowditcii. H. I., A brief plea for an Ambulance System for the Army of the United States, Boston, 1863 ; and On Pleuritic Effusions, and the necessity of Paracentesis for their removal. Am. Jour. Sled. Sci., Vol. XXIII, 1852, p. 320; Brinton, J. 11. , Consolidated Statement of Gunshot Wounds, Washington, 1863; Becker, A. R., Gunshot Wounds, Particularly those caused by newly invented missiles, 1665 ; BUCK, G., History of a Case of Partial Reconstruction of the Face, Albany, 1864; and, Case of destruction of the body of the Lower Jaw and extensive disfiguration of the Face from a Shell Wound, Albany, 1866; and. Description of an Improved Extension Apparatus for the treatment of Fracture of the Thigh, New York. 1867 ; DERRY, G., The Le^^soiv: of the War to the Medical Profession, 5Iass. 5Iod. Soc. Pub. Vol. 2, Boston, 1867; Ellis, T. T., Leaves from the Diary of an Army S'urgeon. New York. 1863; Green, J., On Amputation of the Thigh, Boston 5Icd. and Surg. Joiu*., June, 1863; Eve, P. F., A Contribution to the History of the lUp-Joint Operations Performed during the late Civil War, in Transactions Am. 5Ied. Association, Vol. XVIIT, pp. 2.56, 263; Gay, G. II., A few Remarks on the J^rimary Treatment of INTEODUCTION. XXI The bulk of these documents were received from the officer entrusted with turning over public propei'ty under the convention between General Sherman and General Johnston, April 26th, 1865. Other fragmentary portions were obtained from defeated and retreating forces, or from captured places. It is greatly to be deplored that many more of these precious doc- uments were destroyed than were preserved, — being burned or scattered to the winds wan- tonly, or in ignorance of their value. It must be admitted further, that a few of the volun- teer medical officers retained, for their private use, medical documents and pathological preparations that came into their possession. It is difficult to understand such dereliction of duty, in view of the certainty of detection, since the publication or the exhibition of such data alone would involve an admission of disobedience of orders. The Confederate medical records in the possession of this Office appear, as a general rule, to have been kept with commendable exactness, and it is remarkable that physicians called suddenly from civil practice should have so speedily mastered the intricacies of mili- tary routine. The forms were, in nearly all instances, identical with those employed prior to the war in the United States Army, and the medical regulations were almost liter- ally the same, with the exception, in both cases, of the substitution of the words Con- federate States for United States, wherever the latter occurred. The organization of the medical hierarchy was very similar to that of the Union Army. There was a Surgeon General, assisted by Medical Directors and Medical Inspectors, assigned to military depart- ments or to armies in the field ; a regular staff, composed chiefly of officers who had with- drawn from the old army or navy, who signed as Surgeons or Assistant Surgeons, C. S. A., a corps analogous to the Staff Surgeons of Volunteers of the Union Army, its members being addressed as Surgeons or Assistant Surgeons P. A. C. S.;* regimental surgeons and assistant surgeons, and physicians employed by contract. The inspections appear to have been frequent and thorough, and special commissions were sometimes instituted to enquire into the prevalence of hospital gangrene, erysipelas, tetanus, scurvy, and various epi demies. f Among the means adopted in the Confederate army for collecting information on spe- cial subjects in military medicine, surgery, and hygiene, was the organization of a society of surgeons of the army and of the navy at Richmond. The following circulars will indicate Wounds received in haWe, Boston, 1862 ; GOLDSivniii, M., A Report on Hospital Gangrene, Erysipelas, and Pyiemia, as observed in (he Departments of the Ohio and Cumberland, Louisville, 1863; IIODGEX, J. T., Wound of Brain, St. Louis Jled. and Sur. Jour., Vol. V, 1868, p. 405; Surgeons Reel and Artery Forceps, St. Louis Med. and Surg. Jour., Vol. IV, 1867, p. 151 ; and On Fractures, St. Louis Med. and Surg. Jour., Vol. VII, 1870 ; HUDSON, E. D., Save the Arm, Remarks on Exsection, etc.. New York, 1864 ; and Mechanical Surgery, New York, 1871 ; HORWiiz. P. J., Report of Casualties from Gun- shot Wounds in the U. S. Navy, from April 2d, 1861, to June 30th, 1865, Washington, 1866 ; Letteumax, J., Medical Recollections of the Army of the Potomac, New York, 1866; Lidell, J. A., A Memoir on Osieo-myelitis, New York, 1866; and. On the Wounds of Blood-Vessels, etc.; On the Secondary Traumatic Lesions of Bone., etc.; and, On Pycemia, New York, 1870; Mott, V., Usemorrhage from Wounds and the best means of Arresting it, New York, 1860 ; MITCHELL, S. W., Injuries of Nerves and Their Consequences, Philadelphia, 1872 ; 3IOSES, I., Surgical Notes of Gunshot Injuries occurring during the advance of the Army of the Cumberland, 1863, Am. Jour. Med. Sci., Vol. XLVII, p. 324, 1864 ; McGill, G. M., Observation Book, National and Hicks U. S. A. General Hospitals, Baltimore, Maryland, Baltimore, 1865-(i6; OkdhoXAUX, J., Manual of Instructions for Military Surgeons, on the Examination of Recruits and Discharge of Soldiers, New York, 1863 ; Oils, G. A., Surgical Part of the Reports on the Nature and Extent of the Materials available for the Preparation of a Medical and Surgical History of the Rebellion, being Part I, of Circular 6, S. G. ()., 1865 ; and A Report on Ai iputation at the Hip-Joint in Military Surgery, Circular 7, S. G. O., 1867 ; and A Report on Excision of the Head of the Femur for Gunshot Injury, Circular No. 2, S. G. O., 1809 ; and A Report of Surgical Cases treated in the Army of the United States from I860 to 1871. Circular No. 3, S. G. O.. 1871 ; PaCKAkd, J. II., A Handbook of Operative Surgery, Philadelphia, 1870; Smith, II. II., Principles and Practice of Surgery, Philadelphia, 1863; Smith, N. R.; Treatment of Fractures of the lower extremity by the use of the Anterior Suspensory Apparatus, 8vo., Baltimore, 1867 ; Smith, D., Experiences in the Practice of Military Surgery, Am. Times, 1862, Vol. IV, p. 331; Smith, G. K., The Insertion of the Capsular Ligament of the Hip-Joint, and its Relation to Intro- Capsular Fracture, New York, 1862; THOMSON, W., Report of Cases of Hospital Gangrene treated in Douglas Hospital. Washington, D. C., Am. Jour. Med. Sci., Vol. XLVII, 18C4, p. 378; Wagxeu, C., Report of Interesting Surgical Operations, Performed at the U. S. Army General Hospital. Beverly. New Jei’scy, 1864 ; WOODWARD, Report on the Causes and Pathology of Pytemia, Trans. Am. Med. Assoc.. Vol., p. 172, 1866; Ukad, J. B.. Report on Wounds of the large Joints, Southern Sled, and Surg. Journal, July and October, 1866. * I’rovisional Army of the Confederate States. t Some of these reports, on gangrene, typhoid fever, and the mortality of prisoners at Andcrsonville, have been i)iiblished by the Sanitary ('< m- inission : Memoirs of the. War of the Rebellion, Vol. I, 1867. Vol. II, 1871, New York. Huid and Houghton. 8 vo. pp. 6(i7. 580. wUh colored plates XXII INTEOD UCTION. the general scope of their inquiries. Keference is frequently made in this work to the printed and unpublished proceedings of this society : “Sir: With the view of reeching the individual experience and opinions of surgeons and assistant surgeons on debatable ])oints in surgical pathology, based upon their observations in this war, an ^Association of Army and Navy Surgeons^ has been organized, and your co-operation in carrying out the successful fultilinent of its purpose is solicited. Questions proi)osed by the president will be forwarded, and as early a reply as practicable will be necessary in order that a majority vote may be taken in the decision. The following are the questions: I. In gunsliot ■wounds, do such differences exist between the orifices of entrance and exit as to indicate them with certainty? II. Have gunshot wounds, in youi’ experience, ever assumed tlie appearance of incised wounds and healed by first intention ? III. When suppurating, which oiifico seems to heal first? SAM’L PRESTON MOORE, Pres’t jlss’n A. N. Surgeons. Sir: In replying to questions, and in essays or papers .sent to the association, a rmtwe is requested, coming to some conclusion, in order to facilitate taking the vote in the decision on the subject. The following questions are proposed? I. Any DEATH from chloroform in YOUU practice? Give particulars of the case, if any. Is this agent always used? II. 1st. Does ‘shock’ postpone YttUIi surgical interference ? At what period of time, after injury, are YOU usually able to operate? 2d. Any relation between the chaeacteii of the injury and the geavity of the shock? 3d. Any death, in your practice, fi’om shock alone? III. Do CICATEICES from gunshot wounds furnish YOU information as to the nature of the missile which caused the injury, and the probable exteance and exit of the same? Further particulars on these subjects, with accounts of any remarkable course which balls may hiive taken in transit through the body, in your own practice, are solicited. Third .series of questions : V. What NUilBEE of cases have been followed by .secoxdaey haemorrhage after ligation of artery ABOVE the wound ? Mention vessel, part of artery wounded, and the point ligated. VI. In arresting hsemorrhage, has local deligation, or ligature above the wound proved the safer method in YOUE hands? In how many cases have you resorted to the one or the other? Mention vessels injured. VII. Have haemostatics proved of any avail in YOUE experience? How have they been used? VIH. How many cases of GAXGEEXE have followed ligation for pei.maey ha?morrhage and how many for secoxdaey haemorrhage?” The replies to these enquiries, and the discussions on the subjects to which they relate, furnished much interesting material, which has been partly compiled and published in the first volume of the Confederate States Medical and Surgical Journal, and as the fourteen numbers of that work that were published are now very rare, no hesitation has been felt in reproducing, with due acknowledgment, the reports of cases, clinical records, debates, and discussions, in which the surgical experience acquired by the Confederate medical officers is partially set forth. The general conclusions will be found to corroborate, in most instances, those accepted by. the surgeons of the Union Army. This is conspicuously true in regard to the relinquishment of depleting measures in the treatment of gunshot wounds of the chest, in the sound practice that gradually came to prevail in the treatment of wounds of arteries, and in the estimates formed of the applicability of the special excisions, and the < limits to be assigned to conservative measures. On one point, the closing of gunshot flesh wounds after their conversion into incised wounds, with the hope of healing by first inten- tion, a procedure warmly advocated by the Confederate surgeons Chisolm and Michel, the theory and practice were alike rejected by the Union surgeons. The plan was tried in the Uew Zealand war, by instructions of the English’Director-General, but the reports of Inspector General Mouat, and of Staff-Surgeon A. D. Home, though nob decisive, were unfavorable. INTRODUCTION. XXIII Since the conclusion of our own struggle, two great wars have convulsed Euiope, — the Austro-Prusso-Italian, or “Six Weeks’ War” of 1866, and the German- French Wai of 1870-71. It has been sought to compare our results with those set forth in the already numerous publications of the German and French military surgeons. ‘ I have also contin- ually referred to the reports of the antecedent or contemporaneous or subsequent wars in Algeria,^ in Schleswig-Holstein (1848-50),^ in the Crimea (1854-56), in Italy (1859),® in the Prusso-Hanish War of 1864,® in the Sepoy Mutiny,'’' and the Fnglish and French expe- ditions to China,® the Hew Zealand AVar (1863-65),''’ and the Abyssinian invasion (1868).’“ ^ BOYON, A., Xote.s et Souvenirs d'lin Oiirurgien D' Ambulance, Paris, ISIH ; GliKrxoiS, E. IJisfoire Medicale du Blocus de Metz, Metz, 187*2 : Cm- PAULT, A., Fractures par Armes tt Feu, Expectation, Fesection sous-Periostie, Evidement- Amputation, Armee de la Loire, Paris, 1872; Vaslin, L., l^tude sur les Plaies par Armes d Feu, Paris, 1872 ; FlSCIIEn, H., Kriegschirurgische Erfahrungcn, Erlangen, 1872 ; Ll5 Four. L., La Chirurgie MiUtaire ct les Societes de Secours en France et d I Stranger. Paris, 1872 ; MacCoumAC. W., Notes and KecoUections of an Ambulance. Surgeon, London, 1871 ; Mac- POW ALL, C. J. F. S.. On a New Method of Treating ( Grubg's System ) and the Medical and Surgical Aspects of the Siege of Paris, London. 1871 ; BilluoTII. T.. Chirurgische Briefcatts den Kriegs-Lazarethenin Weissenburg und Mannheim, 1870, Berlin, 1872; De;5PU^:s, A., Rapport sur les Travauxde la leme Ambulance d V Armee du Rhin et d V Armee. de la Loire, Paris, 1871 ; Sazarin, M. C., Clinique Chirurgicalc de V llopital Mllitairede Strasbourg, Strasbourg, 1870; ScHATZ, J., ^tude sur les Hopitaux sous Tentes, Paris, 1870; Bon'XAFO.n'T, J. P., Da Fonctionnement des Ambulances CiviUs et Inter- nationales sur le Champ de Bataille, Paris, 1870; Langexiikck, B., Ueber die Schusswunden der Gelenice und ihre. Bcliandlung, Berlin, 1868; Passa- VANT, G., Bemerlcungen aus dem Gebiete.der Kriegschirurgic, Berlin, 1871; Iwaxoff, Bericht ueber die Besichtigung der Militdr-Sanitdtsanstaltenin Deutschland, Lothringen und Elsass im Jahre. 1870, von N. PirogolF, Leipsig, 1871 ; RUPPIIECIIT, L., Mditdrdrztliche Erfahrungcn wdhrend des fran- zusischen Krieges im Jahre 1^70-71, 'WdYzhiiT^, iSll : ECKtlAIlT, Geschichte des Jc. b. Aufnahms-Feldspitals XII, im Kricge. gegen Frankreich \%7\)-7\, AViirzburg, 1871 ; BECK, Kriegs-chirurgische Erfahrungcn wdhrend des Feldzugcs 18()G in Suddeutschland, Freibiu*g, 1867; SlMOX, G., Mitthcilungen aus der Chirurgischen Klinik, Prag, 1868; BOALDES, A. W. HE, Des fractures compliquees de la cuisse par Armes de guerre, Paris, 1871 ; CouviiA, Des Troubles trophiques consecutifs aux Lesions traumatiques de la Moelle et des Nerfs ; CllUlSTdT, F., Du Drainage dans les Plaies par Armes de Guerre, Paris, 1871; QUESXOY. F., Campagne del%70, Armee. du Rhin, Camp de Chalons, Bomy, Rezonville ou Gravelotte, Blocus de Metz, Paris, 1871; Laiouk, A., Journal du hombardement de Chdtillon, Paris, 1871 ; JoULlX, Les caravanes d'un chirurgien d'ambvlances, Paris, 1871. ^BehtiiEUAXD, a., Campagnes de Kabylie, Paris, 1862; BauDEXS, Clinique des Plaies (T Armes d Feu, Paris, 1836; BaI’DENS, Relation Uis- torique de V Exphlition de Tagdempt, Pans, IHAI K., V Algerie Medicale, Paris, 1854; ViXCEXT, Expose clinique des Maladies des Kabyles, Paris, 1862; S^:oiLLOT, C., Campagnes de Constantine de 1837, Paris, 1838; ]\IAUIT, Hygiene de VAlgerie, Paris, 1862; LecEUC, Une Mission Medicale en Kabylie, Paris, 1864. ® Stuomicyeu, L., Maximen der Hannover, 1855; ESMAUCII, F., Besclireibung einer Resectionsschiene. Ein Beitrag zur Conser vativen Kriegsheilkunst, mit fiXnf Holzschnitten, Kiel, 1859, and Ueber Resectionen nach Schusswunden, Kiel. 1851 ; ScilWAUTZ, II., Beitrdge zur Lchrc von den Schusswunden: gesammelt in den Feldzugen der Jahre 1848-50, Schleswig, 1854; GUULT, E., Militdr-Chirurgische Fragmente, Berlin, 1864; LoumeyEU, Bie .S'c/tasstiJMnc/c/i und ihre Bchandlung, Goettingen, 1859 ; Lcefleu, Grundsdtze und Regelnfiir die Behandlung der Schusswunden im Kriege, Berlin, 1859 ; BECK, Die Schusswunden, Heidelberg, 1850 ; Stuomeyeu, Ueber die hei Schusswunden vorkommenden Knochen- Verletzungen, Freiburg, 1850. The principal authorities on the Surgery of the Crimean War are: M.vniiEW, T. P., Surgical Part of \he Medical and Surgical History of the British Army in the Crimea, during the JPar against Russia, in the years 1855 and 1856, London, 1858, Vol. II, p. 253; CUEXU, J. C., Rapport au Con- seil de Sante des Armees sur les Resuliats du Service Medico- Chirurgical aux ambulances de Ct'imh et aux Hopitaux Militaires Fran^ais en Tiirquie pen- dant la Campagne (T Orient en 1854-1856, Paris, 1865 ; PiROcOFF, N., Grundzuge der allgemeinen Kriegsehirurgie nach Reminiscenzen aus den Kriegen in der Krim und in dem Kaukasus, Leipzig, 1864 ; Scuive, G., Relation Medico- Chirurgical de la Campagne d'Orient, Paris, 1857 ; Baudf.XS, L., La Guerre de Crimec, les Campements, les Abris, les Ambulances, les Hopitaux, etc. < etc., etc., Deuxieme Edition, Paris. 1858 ; Fraseu, P., A Treatiseupon Pene- trating Wminds of the Chest, London, 1859; Legouest, L., TraiU de Chirurgie d' Armee, Paris, 1863; SalleuoX, M., in Rccueil dc Mem. de .Med. tt de Chir. Mil., 2e S^rie, T. 21, 1858, p. 320 ; LawsoX, On Gunshot Wounds of the. Thorax, London; Akmaxd, A., Histoire Medico-Clururgicalc de la Guerre de Crimee, Paris. 1858; BLEXKIXS, On Gunshot Wounds, in 8th ed. of Cooper's Dictionary, London, 1869; B.\UDENS, L., Souvenirs d'une Mission Medicale a V Armee. d' Orient, Paris, 1857; MACLEOD, G. H. B., Notes on the Surgery of the TPar in the Crimea, London, 1858; Cazal.vs, L., Maladie.s de V Armee d' Orient, Vans,, 1860; POUTA, Della Disarticulazionc del Cotile, Milano, I860; Makuoix, Histoire Mddicale de la Flotte. Fraiu^aise dans la Mcr Noire pendant la Guerre, de Crimee, Paris, 1661. ® CiiEXU, J. C., Statistique. M^ico- Chirurgicalc de la Campagne d'ltalie en 1859 et 1860, Paris, 1869 ; Rodolfi, R., Campagna Chirurgica del 1866 Osservazioni Cliniche, Milano, 1867 ; GlIERiXl, A., Vade Mecumper le Ferite D'Arma da Fuoco, Milano, 1866; GuiTTi, R., Dell Fratture del F* morc per Arma da Fuoco, Milano, 1866; ROUX, J., De V Osteomyelite et des Amputations Secondaires d la Suite des Coups di Feu, Paris, 1860; Apfia, P. L.. The Ambulance Surgeon, Edinburgh. 1862; DEMMIC, H., Studien. AUgemeine Chirurgie der Kriegswunden,'\\\irLh\iT^, •, StuoMEYEU, ucher Schusswunden im Jahre Hannover, 1867 ; LOHMEYEU, C. F., Die Schusswunden und ihre Behandlung, kurz bearbcilct, Gottingen, 1859; Billroth, T., Ilistorische Studien uber die Be.urtheilung und Behandlung der Schusswunden vom 15. Jahrhundert bis avf die neueste Zeit, Berlin, 1859 ; Bertheraxd, Campagne d'ltalie, Paris, 1860 ; BruCK, A., Observations in the Military Hospitals of Dresden, London^ 1866 ; Maas, II.. Kr-egsehirur- gischc Beitrdge aus dem Jahre 1866, Breslau, 1870; Gurlt, E., Der Internationale Schutz der im Fclde. Verwundeten und Krkrankten Krieger, etc.. Ber- lin, 1869 ; BOUDIX, J. C. M., Souvenirs dc la Campagne d'ltalie., Paris, 1861 ; Ev’AXS, T. W., Les Institutions Sanitaires pendaid le CnnJIit Austro- Prussien- Italien, Paris, 1867; XEl'DORFER, Handbuch der KHegschirurgic, Leipzig, 1864 ; Cazalas, Maladies de V Armees d'ltalie, Paris, 1864. ®IlAXXOVER, A., Das Endre.sultat der Resectionen im Kriege in den Unterklassen der Ddnischrn Armee, und Die Ddnischni Invalidcn aus dem Kriege 1864, Berlin, 1870, (from vox Laxgexrec’K's Arch. f. k. ch. B. XII, II. 2); L(T.FLER, F., Gcneral-Bericht uber den Gesundheitsdien. t im Fchl- zugc gegeri Bdnem/zrA*. 1864, Berlin, 1867 ; IIEIXE, C., Die Schvssvcrletzungen der unteren Berlin, 1866 ; OCinvADT, Krieg.xldrurgisdu Erfahrungcn, Berlin, 18(j5; Uessel, J., Die Kriegshospitdhr des St. Johanniter-ordens ini'Ddnischen FeMzugc von 1864, Breslau, 1866. ^ Williamson, G., Military Surgery, London, 1863: Fayrer, J., Clinical Surgery -tn India, London, 1866; COLE. J. J.. Military Surgery or Experience of a Field Practice in India during the yejirs 1848 and 1849, London. 1852; GORDON', C. A., Experiences of an Army Surgeon in India, Londtn, 1872. ^^Castaxo. F.. VExpidition de Chine, Paris, 1864; Didiot, Relatimi Medico Onir rgicale de. I Expedition de Cochinehine, Paris, 186.5; Laure. Histoire medicale de la Marine Fran(^aise. pendant les Expeditions de Chine et de Cochinehine, Paris, 1864. ® MOUAT, J., Special Report on Wounds arul Injuries Received in Battle., Extracted from the Mwlieal and Surgical History of the > cw /e.aland War, London, 1867. General KAiTF.rds Official Report, London. 1869 ; Papers connected with the Abyssinian Expedition. prcBcntcd to bi th Houses of Parliamcct, 1867. XXIV INTEODUCTIOX. In arranging, the surgical data of the American war, it has been thought wisest to pro- ceed from particulars to generals, and to begin with an account of the special wounds and injuries. Several advantages are secured by this arrangement. Thus the returns to the Adjutant General, Quartermaster General, and Surgeon General differ in their aggregates of killed in battle, and there are discrepancies in the reports of wounded in action made to the Adjutant General and to the Surgeon General. These statistics are still undergoing revision, and it may reasonably be anticipated that near approximations will be ulti- mately attained. Although the memoranda of 205,235 cases of wounds and injuries, including 39,163 operations, have been examined and compared and placed upon the per- manent registers, yet many thousands of cases, belonging chiefly to classes not considered in the first volume, remain to be investigated and entered. Hence generalizations on the relative frequency of wounds according to regions, would be premature. The influence of climate and other hygienic conditions on the state of health of the troops, and conse- quently on the residts of wounds, can be more readily appreciated when the Tables in the Medical Volume of Part I, shall have been discussed. Deductions derived from the vital statistics of the Provost Marshal General’s Bureau, from the Census returns, and from the reports of the Commissioner of Pensions, will afford further data for general conclusions. From these and other considerations, it has been decided to postpone the general observa- tions to a later portion of the work. A chronological table of engagements and battles, compiled from ofiicial sources where practicable, but often from popular estimates that appeared to be honest attempts at fair approximations, and sometimes from almost any statement available that was not obviously false — such a table, in which completeness rather than unattainable accuracy is sought, is introduced to indicate the actions that were fought during the period of four years during which the war was protracted, from April, 1861, to April, 1865. The surgical history proper follows, and is continued through five chapters, the first chapter being devoted to wounds and injuries of the head, the second to those of the face, the third to those of the neck, the fourth to those in which injury of the spinal column was the most prominent fea- ture, and the fifth to wounds and injuries of the chest. The operations performed are con- sidered in connection with the injuries of each region, an arrangement much more difficult than a distinct classification, but affording many advantages, in avoiding repetitions and in presenting each subject as a whole. In the second volume, now nearly ready for the press, the wounds and injuries of the abdomen, pelvis, and genito-urinary organs, the upper and lower extremities with the amputations and excisions, are discussed ; and in the third vol- ume, gunshot wounds in general, with the complications of pyaemia, gangrene, tetanus, and secondary haemorrhage will be considered, and also the materia chirurgica, the transporta- tion and field supplies of the wounded. It has been mentioned that the cases belonging to the regions which will come first under consideration, have been examined with especial care, and there are here probably few omissions, the aggregates being even larger than called for by the returns on the monthly reports, doubtless because of the number of Confederate cases adduced. Yet among these few omissions, it must be anticipated that some cases of especial interest may be included. Wounded officers, for example, were often treated in private quarters, and in many or most instances, it has been difficult to procure precise narratives of their cases. INTRODUCTION. XXV The preliminary reports and the prefatory and introductory matter in the medical volume and in this, sufficiently place in evidence the impossibility of compiling a satisfac- tory surgical history of the war by the simple consolidation of data derived from any con- secutive series of reports in existence. The inadequacy of the entries in the class than- atiei of the monthly report of sick and wounded was early acknowledged, and it was officially declared that previous to September, 1862, “the surgical statistics of the war were absolutely worthless,” and that “the only information procurable is such as can be derived from the examination of a mass of reports, all of which present merely certain figures under the vague and unsatisfactory* heading, Vulnus sdo’peticufmy'^ After the revision of the forms of reports and the addition in June, 1862, of the “tabular statement of gunshot wounds and operations,” the consolidations for the first two quarters of 1863 were found to abound in errors to such an extent that it was deemed inexpedient to print them. The quarterly reports of wounded and of surgical operations {ante, p. xvi) and the nominal lists of casualties in battle were required in September and November, 1863 ; the classified return of wounds and iniuries received in action was instituted in March, 1864. The following is a consolidation of the aggregates of entries in Class V, of the monthly reports of sick and wounded, from May 1st, 1861, to June 30th, 1865, as printed in tables of the Medical Volume of Part I : 1 CLASSIFICATION. WniTE Troops. COLORED Troops. TOTAL. Cases. Deaths. Cases. Deaths. Cases. Deaths. 1 Burns 9,487 94 613 4 10,100 98 2 Contusions 44,323 161 2,649 11 46,972 172 3 Concussion of Brain 873 193 49 22 922 215 4 Compression of Braint 61 17 61 17 5 Drowning 672 125 797 6 • Sprains 38,387 3 4,317 42,704 3 7 Dislocations.- 2,908 9 108 1 3,016 10 8 Fractures 1,287 53 1,287 53 9 Simple Fractures 4,215 61 131 15 4,346 76 10 Compound Fractures 1,316 378 55 19 1,371 397 11 Gunshot Wounds 229,119 32,731 6,466 922 235,585 33,653 12 ' Incised Wounds 21,444 186 1,305 3 22,749 189 13 Lacerated Wounds 14,153 459 595 8 14,748 467 14 Punctured W'’ounds 5,285 191 499 8 5,784 199 15 Poisoning 3,087 93 67 17 3,154 no 16 Other Accidents and Injuries 13,099 1,003 2,174 72 15,273 1,075 Aggregates 389,044 36,304 19,028 1,227 408,072 37,531 * Circular No. 9, S. G. O., July 1st, 18G3. Consolidated Statement of Gunshot Wounds. liy Surgeon .1. H. liui.NTON, U. S. V. t After .Tune 3Cth, ]8fi3, this olnss wns iled by the faithful and indefatigable chief <4erk of the Surgical Division, Mr. FkedkuicK R. Sparks, indicates the following losses: Union Troops, killed 59 , 860 , wounded 280 , 040 , missing 184,791. Confederate Troops, killed 51 , 425 , wounded 227,871, missing 384,281. The last aggregate includes the armies surrendered. Allowing for many exaggerations and omissions, the errors appear to balance remarkably, and the results to correspond with statistics derived from entirely different sources. t In the fifty-fourth volume of the Medico- Chirurgical Transactions is an article of fifty-two pages, by Deputy Inspector-General T. Longmore, C. B., on the classification and tabulation of injuries and surgical operations in time of war, in which he claims that some of the best established rules of field surgerj', especially as regards gunshot injuries, have been attained by the collection of the statistical results of expectant and operative treatment; describes the classification adopted in the British army and those of other countries ; considers how far those statistics are comparable ; discusses which system ensures the greatest accuracy and completeness, with the greatest economy of labor and cost in compilation ; advocates an international congress for the adoption of a uniform system, and concludes that the British system is the best. I cannot ft)llow him through this discussion, but must con'cct several serious errors in liis remising that the figures of our tabular statements are “almost practically worthless,” Dr. Longmore remarks that “the vast amount of labor and time ” expended in their compilation was such that “as tlie documents successively arrived at the Surgeon General's Office in Washington, a large number of medical officers and clerks were occupied in classifying and transcribing their contents ’’ (p. 223) ; and elsewhere, more specifically (p. 243), “the labor on the American system is .so great that an American friend once informed me that when he was in Washington there were two hundred intelligent clerics employed at the Surgeon General's Office in collecting and airanging the surgical statistics of the war, for the preparation and publication (ff wdiich a vory large sum of money had been liberally granted by Congress.” I am sure that Dr. I.iongmore will wash to correct these misrepresentations. The maximum force employed, at any time, at the Surgeon General's Office, upon the surgical statistics of the war. has been one medical officer, one clerli, and sixteen hospital stewards, occasionally aided by one acting assistant surgeon : and the “very large sum of money ” (£6,000), voted for the preparation of five thousand copies of the medical and surgical volumes of the First Part of the Medical and Surgical History of the AVar, only subserved its purpose because nearly all those occupied with the work were already in Government employ. I will not complain of the unfairness of contrasting the results of the preliminary report in Circular No. 6 with the perfected histories of Dr. Matthew’ and AL Clienu ; but I do complain of an “ American System ” being described and unfavorably contrasted with the classification of Inspector-General Taylor, when, as I have shown, there was no complete series of surgical reports in the Army of the United States, and information w’as of necessity to be derived from heterogeneous data. “ The surgeons in the field on the American system * * make no distinction between the various kinds of cranial fractures. * * Where all such injuries are tabulated together, as they are in the primary American returns, what useful information can be obtained from a table showing, for example, the results of the operation of trephining?” (p. 240). I cordially concur in the warm praise accorded to the histories of the Crimean and Italian campaigns by M. C’hcnu. I w'ill obsciwo that in his latter work he very materially modifies the classification employed in the former. In the history* of the surgery of the Italian war. he n'ports nine cases of trephining ; in his Crimean history Dr. Alatthew* reports twenty-six cases. I shall record tw'o hundred and twenty cases, and shall be disappointed if their results afford no useful infunnati ;n. Dr. Tajdor's classification may be excellent for the British army, w’ith its corps (T trained medical <'fficcrs; it could not have been advantageously introduced in (uir seiwficc, chietly attended by surgeons hastily called from civil life. Dr. Longmore says (p. 235) that in Germany “no fixed classification exists.” This is quite true, yet the statistical work of General- Artz, Dr. Loefllcr, is a marvel of accuracy and completeness to those who occupy themselves with these studies; and the cxten « -a |H . o K g' d o .a^2 o 3 S iJ I - ■e t; ^ O o 'T3 g- p. <: O O P5 3'a o ‘3!^^ as — o ■3 1 O 2 > *5 . iQ’Xt c ^ c3 ^ lO 5- - O ^ 'd ^ a> o . r« L's.S o§? do*^ • o ;2 d tT ■§ K O O! - o’ ® ■-loo .b'S*; 1 li Q S ^ « jgU o 3 h ■g g d s o P «s flj • 'S gcii-i o./-? 'o OJ i i-i’ a ^ d 5 d*| p' p 1^. ad xjd .S- p.l> p . •C O CP a-d <© c K P- s .2 a u o JgO O cc S ^ ■g = .5 ^ 4i « rt £c « •Iga di o .a m' «►§* d ■S'S & •- TS C 'C 4^ .2 S •-“ C3 c la c. o .2 o « t> eL c s c® £• K '"Q §"5! 05 tn c3 ■£ _ P .2 4)^ kj c ■« 7 o o b*o'^ o i ©’< H I- 2 o A > & & o o O O p ® « a « 2 5 CO 6 ^ 'J’ ‘C *0 3 P o C3 VI ^ -2 n S ■5 :S « s 2 o ® ^ p 'B o ’Sd3 »> <3 ^ b X3 ^ 42 -i: ®'o ^ p J3 4> £1 -•d -d P CO P •6 n a 3^ . ® let: °f S.^ ® ‘ES a a a -o > .2 O > c3 0> C3 is I I S S ^ ^ a Q •e-" ■< P s .2 d p p 20 'a in P'C pW a«M'd i°§ cS I fe g a P o ♦J > o St: £< u? E >* HH c o o .1-3 1 s 0 1 ■§ . ^ 9 » .* o £p > ^•a fe .s’ •S’ !> bo .a t> a" <0 a tio JH X a O rP . ?< 5 'C 'd fcp <3 « a July Gth, ENGAGEMENTS AND BATTLES. XXXV A •5 r' (o -fl CO ;£, •2^ fl us ^ -S) cj *3 ^ a> o -O m cii'^ cd c •— • ;2«P2 'tS o O’- ^ a c a bo^ -3 bjD’S ^ c - . rt' rtttS " ^ «*H *-5 O TS" W ^ c5 o > CC Id O OJ ^ hi C^'c Ph O a o o ^ lls-li s S Sos .2 'S ffi « «o ’S’® S 03 §1 -4 o 1^ ^ . - o ^ bo . ■e ®i2f C ^ C3 g.'s^ < b” gSM CO ’C5 t3 3 ^ c a 3 c3 rt .2 ^ o 2 CM oH o s Si a a ^3 S-a '^‘ 0} <2 a o j I o£ «M 'a 33 rt o c 2 m 2'«iS ^ Ch O TJ «-< &i 0) a ^ o ? .O 2 a a 'a o ,a> 1 rt lO .— » . ® ca s|g -It '« a i > > s p JS p p ^1 <1 "a Jos q* --d ro-iSO’ i2 a> ^ S ® oq lib S S D i>i a -U>H S '1°^ , a J r ^ p a PCi^^ci 4) L-3^ o “^-a-g ^ “5-^3 §-^03 g 3“^. a la's « g.§ J =|'S S53 ,(■;§ -S s? g q •= r ■ " o -sasa a c3 c ; ;:a s : o ^ 3 ’-S c a" 5a»H".§>.„ai» q““ J i! 0 m § g 5^^ ^^taap'o §0 1 p 1 p 'i ■§> g ’S) be p 3 0 S' > p‘ 3 i> ■a ;> .2 " 3 SP 1 “ 0 a .2 ? 0 3 a 3 3 3 '? p ?: 'd’ 0 P 3 CO 2 n 0 a 3 3 0 3 3 0 S aa 1 6 -* b ?5 n a Q > a 3 .a” !> a a a .2 a a •q a o 2 •?: a C4 a a -” .i S = s t; ^ ^ a J3 3 3 q* 3 3 £ £ c3 ^ >»>»>* 3 3 3 5 SC'S Ci (?< c* 3 XXXVI CHRONOLOGICAL SUMMARY OF < ®.£i i § s '2 C s S 2 t .«|5 £ £ ^ 5 p be p * <*- g <1) o P i-t J- s S .§ t: •? " G ^ P Em c S ^ « tc S- o ?5 e o c p *a''S o «i^k o a ^ OlJ Ifc ^ K K igx O c. « C3 c! ^5 •ii O P O K «j £ P Cl > § 2 Cj t. tp c c ra P!.-1 f5 S 2- ^«3 U .= M -C C ► P-t: o c < 10 0,2 •SGlS«IItt •pepuno^V 'p^nni •SuiSSTJ\[ •papunojVV •psiHH ?^=>S ! ^rH C S 3 ..-2 ^ £'-'cf) I ill S 2 . p *2 W P s ^ "K o 2 i S •§ . o CO g ti S - X-g j2 § § i'^ £c5 g &g B 2 E ^^3 S o o « S 0*2 S ■ -5 1^1 >o c ^ ® c s"" I p.i •p^ ^ O s -fc p s fl MM tJ -'C s 5 •E p seq 3 S I 1? p •a > » -g 3-. ;«■§>•“ 5 „-'SS'^ 3 'g CC r« 'S -ii .« «■§ i bg S = 1 1 •g 1 1 -g M « I o fc, ^ c 5 I p t « S O S "2 e ga s o .5 c c E Q> p « O o 'H ^ ^ 2 s: •P O a ; a g o p >» a tJ a -S E ri: s s . s 8* p .3 a ••^ fcn 53 •g ■& > S fe •& > •§> > ■& > .23 c ^ ® « C3 - 5 C P a ^ CO 5 p c g ^ a 3 ^ "s I C5 fQ % S p u> • c P i5 ■g 6 o ^.S -* o Q O S<5 O 5 a c ^ bo o a > S c3 r«,Q a> ^ C5 ^ => S « <5 5<1 ^ 1- o kI ^ cS .2 ^ ’S 3^ S « o cd t: ^ ^ pf 2 3 rrs eco o O '*5‘ C-xi S-- rt ^■‘ • o >'^ > To^ . C> CO 3 P^ 3 '^3 « 2 2 O 3 C 5 a {£ a a O 'i bo a ^■fco < ia « O O « Eh a a 3 a £? a: *5 *3 2 >* o ;< 5 3 a tc §a a ^ 'd as _r « S CQ a a 3 3 a > ” :H IS « 1 I 1^ ^ 3 a: § ® £ a ^ a ■3 ■“ "2 o" « _ '- ' §) ?5 C 3 ^ m'3 ; & S ^ S .2 a « 5"^ a J3 .O 3 5 If* 3 '-’ Ci a j3 - 5 * • ® ss .a .--a ^ 0) ^ « c .a” 3 2 2^ Ci « w .2 .9 o3 aw £ “ s a a" ^ o < : i 2 o"-. «Oo ^ a « C*3 C .-a •O s Q a a' a .= S ■3 To a '3 a -a 5 bo g I o a ^ a> . W a ^ ! « 02 a: w oj ^ as . fi -H ^ ~3 Cl it as a: ^ ST cT 3 0 * cT 02 tii ir. 'Ji tf. O O XXXVIII CHRONOLOGICAL SUMMARY OF fQ l>. <0 1 G ^ o cffl 5 « . V ts a -r o ticts ’C^ |> 'S ^ p . p o & *S* o 'C «M S o S &'3 a 2 ^ to 3 "5 g ca *—2 hH “ c3 OJ 53 (2 c-oP « S'^Q §■ *f 0 J“ o 6 K CO o ^ 'o fe u S U Pi eco o o 5 ■Co a> fa 'd w p: o .2 c'^.= af^ « a> « " aas-gi ° o c p Of ^ 6 i od®e?£ s o < *" S "p fcr^ *" 8l 2 c ^ t> 42 < “■O '] k3 ^ 60 S 2 S3 B E ^ p’l '2 £ 2 S §§« 5 »rl ^ Of o ® « 2 p o o bo « S o ^ K P -3> U n I gSg P'l l.l « K>.2 Sgl is S's o *^p §D * . Of to faS ^ S PO "p P |S Cf M o Gf p 'S o t, bo c p g-3 K § ■sS .3 e i § o 1 CONFED. LOSS. •^UISSII^ 22 36 5 36 37 4 3 8 o o 31 Cf CO 27 500 36 ‘papanoAV 29 350 1 3 Cf Tj. O 264 200 200 5 5 15 17 ■pailDI 11 8 5 1 62 5 63 3 14 36 30 17 10 3 106 20 8 UNION LOSS. *5aissii\[ • ^ • CO CO CO Cf 445 0 • CO - ; •paptmoAV 2 29 4 ^ in CO 14 226 21 60 0 3 37 15 4 •pail'H 3 14 1 Cf rH Cf CO TI- CD ?f OD Cf ' o i ob « Of § t E< • «Ci u p 'i: o .t: ’“^ JS CO fc* ^ - Of r/. n-« E r 2 e *5 s s ? " >6 43 53 § e P- Of e E§ A 2'^ ■2 S 0) P F| 'C 42 •/ ® 'E cfa 0 C* s« - P 2 P 1 e' B Of Of g P b *0 P §g| 3S-< 5 C %,lt ■•Sag -P P 5;25 r-i 'U O t|-i Of 3 j3 ^ o t:5 S 1.13 "t P CD -SI c CO ” It^ gCT a ► C'l p ^ rf: p Is 11-s g a^ O 3 ^ 3 3 3' « p i. P •- •i-l o 42 *5,- O p fa fa Of ^ •grp s ^ C 3 P P P •I Si •l1” .2 P r? t> boJi: p I” « 3 S| 1 , t' O '-' 'C c2 §l?o .2(£ ^ O oK ►P 'b'2 3S 2 B 'P.p P bcu P Of o-* t: 0 r-* ^ -« 8 I 1 W y ffi CO Q >, P « .•E H I P^.S ri 4 O O z ‘2 0 ■& Of ^ 1 ta' I I K « 3 X Of Cf Ci M 5 6 5 Cf coco ENGAGEMENTS AND BATTLES. XXXIX gCCO *5 • ..2 0^0 3 c P- cc S ^ • 'rt rf) u ^ci ' § rH g tz o 'S*~* ^ 'ii , C Ph ; - c ^ ^ c a) ^ -e ^ o « tc'^E= Q) a © o c -*- •gs.- S 5<.1 «3 .i: ©> o « ®5 • 55 O irT^ <6 © >-5 -3 ^ & > 03 13 P - ea © 13 «M » p o 5 U ti.2 o > Ph P Ph g »|£ ■|k1|5 o ■e ♦. 'P •— ■ tn P P p p* ^■p S © tS^’p la p P «M P ^(*A p o S< P Ph OP© o S'M Si © P «M 5 p ® ® S -*2 S ^ © b o • b tM 2 «*< 2 ° §• .- .a ■KPSCkH 3 a Kps ■3 §” .3 .-o p i-.: p a ^ p C5 O .5 ¥ •2^ P © 03 1 o ©i-?> «<-i O cS O Ph'P , © p .“W S) gs © fee « « fl c o o 2 j3 © © « K >» © E: C3 tC if bt P,| © 2 SI C3 S •5 I sa s o & n| c5 § ■3 I §i 1“ u N 1 § 9Q ,2 o .2 m o a ® o CO rH lO CO «0 rH t^ ^ to CO «0 05 r-» IC CJ 'o « > o c3 ^ O >% 'O o'! a - HH I > >> OJ Eh C 5 o ^ b .2-< c3 a to « '^'oO C c « ♦» SS *o « HH fl ^ ®§ Q -hO §«i?5 '*§ » .2 o S.2 ^ !§ bD •c pKH CO W5 'O 1-^ ^ 'S o c * "OJ • © • 03 ci£ 2 M a> : ^ '■ P ! 9 ti!d3 a : i* i ? : : 3 • o §^3 o — .> r oi P o >, W I ^ I i C o .*2 f S ® 3 9 *3 * O ti^ ) M f o ■§ o iS Sc. B a C.O fi c. ca . * . tx rt to ■■tQM <3 ai'tf . S CC'p t . pO p © r-t W e 3 . Ph tJ f^.S . b* O '■‘■P <• p P P ^ . P it" <2 p 0 ^O * 5 * 1 ^ bfi ‘=^ P Ip S I ^ 3 2 £ M o % c a M 1 o -c O .;5 U tjD £“ K «» S o g § So cc -S o c 5, to? o Th .P O c p 2i *p ►^ © .05 © ^ J CO § 0 Q © e 1 ■S’ > •& > H o ■eg « 3 S (X « c S S ? P O C 5 d O > « -g o © O S .f I •§ *c ^ .p> « a ? CO g o s I O B. S ^ 'd ® p ,3 5 ^ > < 3 5 5 1-* o Cl c< 0 < 5 5 to t^ > o o ?5 ;z; 5<; £ ^ ^ ^ £ o «-H Cl s 05 ^ >c; 5 ^ >c; ^ Cl Cl Cl Cl i ^ £ 'A 'A '•/■, 'A 5 3 ^ Ci Cl Cl O Q Q Q XL CHRONOLOGICAL SUMMARY OF tf ; . 7 : “ - P ! ig <1 C3 . rt 2 ^ ^ - « 3 o «rs =* QJ .2 c > ^rS'C^ *H h C ‘C 2 ^5 K ;4-i 'a fcijrt^sS ^ s a «g|5 “so g« O 2 c ra’ 3 ^ 57^ -S o a ‘ 1 < S !e< o<; o ? o a< ^ O g C !>i)« c a P k|« - £« .2 g'd s= I a Ij - o rt O Pi-O <3 2 ^ fciD ^•n «P5 ■a o tSi « feb §l;l o £.'2 c. o < >. C.2 So i-O! r ^ ^ a ^ c- a ® <1^ S ^ § ■ a Js, .S.1 1 - iy a” 1^0 §1" = 6 °. ti) fl O tn c*;3 .« ^ a a rt 2 fct S 'C ei PO o . t: ^ C.2 g'a ^ a W « ■si li o c <3 ^ a S fex> g.S VSd §1 II til >33 rt a ft g <*H a 2 ft5 o a a 2 g § c-SW ii’Sa o 5 H C3 to P a » o s a; •- a''2 rt <■3“ «.C a &<3<3 • Snissii \[ •popuuo^W • P^IUM •Suissri\[ • papnno ^\^ • psil!>I Q H O c c 55 W •«2 PU O o K H O 5 p 2 o ^ a > -M bo « s c-a c| •vrf a Qj Si's c'5 a p g a rt w ^ *0 '5 a H > o p ^ a> rt s a o a a ^ .a V sps ’-a i 'd 52 c ’§'5i— d .b b > S ■cS (S ss ° « S d si” si I $ _ a t-i a a «- a p CO 1 2 5 a 5 >» .2 5 W g g”a^a 5r3p <: s-c d P a a I 'I % ^ s a § I 1 H 2 C-)-2 S-go ^•r j a 5- bo 'S ^1 ft Qj >» Q P bo « 55 O tt a : as a : as ^ Q Q P Q Q ft 5 £ fi Q ENGAGEMENTS AND BATTLES, XLI « < c 2 i^LO 2 g*. 2K S S P -S ® ^'o < to 5 ’5 ‘ t; Lo cuc^ p IS 3 « ^ -S ; ^ O c3 :< j: S C rj- vr - G ) ,ci rf =: e i •= u U.sll ■" 1 &S |o| fcD<1 ■*■ jh ^ Q *C t>~.Q « ^ n . « 0) -3 ^ o ■/} o) ^ X s K ® o • i;3 N 02 K iLr3 . ■c .73.^ O ^ &sa PS e o „ Sa t; 0) S .2 2 -s S s s « r* c a o agH cs^OiO O < a * • «« '?* a ^ o a 2 JH c 2i a 5 cc<| ^^3 sc a .02 '8 15 is| S 4> ^ c O ^ c w c • a • c S -^ Ch ^ 3 . C <5 >< j3 •'“> o ^ 45 S a> < ^1 ttS 45 4 ) a rt ^tc i ^ a ^ : : V a ,4) .a - •« ^ iB<^< o O Sc I'&g o |l ti to W 5 ^ S tJ rg S a 3 go cC C a O fi ii iS s o c 3 *0 p ’g P g »f s 5; o i?s sa b & = c^ aS 5 ir“ -2 'J ii — O -o o a a tf) ^ 'c .to o 11 §«•■= •-3 C^2 I g>aK^- 5 ; 2itid X <1' - « p O cT B: e , o'saa c E £ S S I id o Q rt 'd a 4) a 'd ►=S a ^ a Ji — .2 3 S-go 5 =B C = ^ fci-; 0) ^ '45 'gc C3 . SJ o X o '3 a fH e3 C*3 >> . 23 -3^ <^•3 fc'a ■£ §0 s 'd'O c ► a a rt *: .K « S 3 .2 4) a a a a ^ 02 C , '3.3’ a w o o fe*J a ^ o a .a bo a o .office 4> Ph i£^^. a^ P «a^ o o 5 -r S ^ "g 4> a ' '' a SI a ^iO g ♦pT - a o a : c o • g3 ; a > fl < I .2o! . ; ^ --■£ i H 1 C a> .. o a c o t Oi o 43 '! 'S ' 11 .a^-^ 4) C O ^ n K' "o o s'*! §.2 >,§ ! to.^ii a K o a a •r 2 3 *3 '1 e P oJ ” ! i s« .2 a tj .2 £ a fe.-a-a .-aU^ 45 4; ^- 05 a w ,„'■ III d N ^ 3^4) a . t-, ^'5% r / ? a Sii ^ s ' ll'S g - i - | PS3 ? 2 « = a , "g ,S 5 - £ w M M S ^ 5) C *'' '*^ 'S ^.- ra ^ - Ci ' S'd t£ --5 a a B r- S 00 ^ a a . a rH . a 5 « er ^ . x s a S H c g*-* -g >» a 3 £ a? - '”' .2 — ’ §p'5'^-^-;o|p 5 ,-r S ? 3 ,2 '3 "a ..^c/a ^ !Z 5 5 c .,- - - a "c o £ ^ >• 5 a 5 = |.a-i^'.ag^ ■a tJD P c t: o to O to W O G= XLII CHRONOLOGICAL SUMMARY OF •c 00 C) 5^ 3:2 i S *0 ^ '3 C3 C> a< Vh c a lo O' si o « 0.2(5 E3.a^ Ci hc2 o3S >5 0! ^ o § «.a TT o'*® »i-rj5 q' "C 0) H bo « Ph cs ^ o ^ s « §■ ^ S a> S I'^'S O .02 . o OQ-g gS o . <1 g o c a^-o gg.a P rt Q O *(« o p4 •P o go .3 3* (S 00 O T-H *2 ‘3 B .9 o a *o O' ^ o eport page O o ■»J « i ” o rvi S 5 ^Cm ^ S^ ^ O g ® rk 5 £3 •5’-''^ § g ° ” *02 P 13 . CO o ^ 'So ^ O _- rt 2"® S « w * Cl c CQ S O d ^ s_, S 2 2 JSrt 2 s 2 p C3 liliil tS^P.wc'S^ — ^ ^ O -P 'rf ffiSWsoC^Mvjo^ *3 p 2 'p •sqs:so«=^ 2 m P bC ^ o e3 , .— 2 2 § .sj p p S 1 '5 S •- O P e 3 fl (h ^ tb *- C5 ..?> tt P/S 3 i.’aW ■» cj o *S :2 ^ fc£ 2 o a.§g'§< B Q teg’ll o .9 O “ ^ 3 0(9 I ^ m _ .2 ^ V 'S o P I o &■« Sv. S — a o. o *i o 9 & (in K §§§ :|i ° S i .2* ^ K< rtcc O CONFED. LOSS. •Saissiia ■* lo • M 1,600 11 15 5 ‘paponoM 5 150 O O , p 3 P o ■o S bo (5 .9 ^ b S) o p W M ►2 > ^ 3 &H bB a P> O Pk B !? .2 O ■| I > I q" bn s o I -' b.2 §.9 ■g. bD St q P* K P^ Ph ENGAGEMENTS AND BATTLES. XLIII l »1 a ? ■■ S a- 1 o to 'C B K< sa; |b O r;B “ill f-H a; ^ *3 a? C; u ^ a • 5 c 5 ■£ M .B (2 si^< TJ ®« 53 Bil a 'o tT Ph « c3 Cj tsD -c.S - 'O c a "" p o o •see (S K Te g ® eg o to 'S'c S ft t^OD fti? Oi o ° S5< O 'rtCC O i .£ ^ S c- .-■Ex- es arl -r«li S *« Tj< 5 ^ ® ^3 C E 'C c§g6o <''3§i'§ . sg"S'S r ® ^ ■a B|_,- (aco! a C3 „ S3 .11 I S « ® 2 oj- . «M ^ 5 i ® P ® E a> b ^ .4 ^ Cm o o « ft o C ^ 5 0 ® -r pq«2 . n:3 e g S'p rK O'* O — T flS t:3^ c ® 0.^5 ^ c'S l&b e <-2 o .£ E O 20 i 413 0 100 * 11 269 93 25 00 3 5 100 106 342 17 60 05 C 5 CP CO 1 - 80 9 15 36 15 CP 00 Cl • 24 35 - 0 CO LP CO n* 4 10 8 2 1 440 22 5 75 10 Cl Cl 0 00 rH 103 1 Cl CP CP •i X f- e "c and New hode 0 X ' 0 b iicut, 9 th th R d Cl d ft 0 *3 CO 0 .0 ® m d § ft d “ g ft d 0 s s Q P ^ p eS X X 0 -C 3 >■ cS O •3 i T.b z Cl 5 ® ^ P g s ^ p *ft ® p p > p p P *E .ft.s X ftps P E Cl “ 3 =f 05 § ■p P § e p p ^P ft 0 s «r 3 ‘C 'c .2 0 d ft , p >* X p 2 Cl e Cl 4* p 0 •i! X X 0 *9 c <: b c ® W 'd •X ^.2 M ^ ^ X S “ *3 ® w ® « c SB “• 3 -g £> § CC - S E X ® ® X ip g •^xo ® te rr « s '^»a “ d s (;; Is ® Q P P Q d >■ eS a I C a X x'^.b ip ^ .#■§1 D Cfl c 8 — 5 ^ >%?? 45 p '^,. ... P X * Q> C 2 ft I- 9 5.2 -5 Sc| § = •5 $ Sr 00 .. *3 X l-sj i gci P X o3 ®00 rt 4* t' HH 43 r-T P ft > go 3 b o .l rt b t Xtt o > « .2 P •S*x p fe X ® si ff 'd C3 .P «£'§ ”£ 5 <^'5 8 c3 O r-.M " & O O •d 2 § bJD CSX to •E ft |Si ^ 1 l X P^ o *5 ® o ft £? .2 U ft aJ c< ® C 2 ft < ft 0.2 rfj M o ® ft^ X I ft *S ft C w h to I ft a 0 1 bo d 2 o X ft . Cl So cj c^ Cl n .c: ' ft d ft ft LP CP Killed, wounded, and missing. XLIV CIIEONOLOGICAL SUMMARY OF 'S’S 55 1? p ■2 2Sl = s--. S P- 5 ^ CC ^ § 3 g -is ^ « . ^ c> j- S ^ s - ssasps-ss “ a = 3 ■§ ^ C N > OJ *3 e!i H I’eI ^ .3 S I cfl & t>. a S ;3 t - -T 5* rt - o ' q '*^ onJ ^ — ^ 2 toS nO K“ }i W Ji- I • - «2 I .’3^ aj ’3 ii o S *c ^ • . S 2 o o j a a o icti « 1-5 <: o 0 i?| S a- 2 I ili' si - Ig .^ Pj s w. ^ w 3 w - sf * .- g . - S o'lc 'S X O ^ ’'■ rt a o _ "a S-ggis ,2 S a 0) o be t: & o o p (OJ 5 5 20 •J^U1SSII\[ to »o o> CO • ' Oi •papuno^V ct CO X) Ci 00 CO rl CO to CO 35 129 •paiUH 1,735 O') Cl Cl CO 10 35 C CO .2 .2 .2 5 '§ f f-g cS a 53 f > P3 O c:-3 •3 *3.-^ c-.'TS r O , «? •' I I 3 P to S ?P — P . i 2 c « ^ P -5? 1 & i Q ii^ls p I J > g . ^ S • c 5 2 a H a 2 §>;£ gs.|,3 si 3 0.3 g '“' fc£ C c5 ^ p'^^^ b'P ;> « - >< • » 3 Ho ^ ^ ^ 5 g rt ' 3 2 p 2 C ^ P :r.^:-i? P'5 s ^ T fcij 5 i Ci .2 .2 .2 ^ ^ ^ ■'5 'o p p p p be fco be bo-*^ 3' c >3 '_S)§^ ^ ^ S 2 = -PJ § p -p p: S c o P .. (rt O P 3 r- ^ OJ *P 3 _ w o ^ 0? to y . o Q ^ O ^ “ . ^ ^ P ^ rt o^i o P ■*' ..o . o • p II 572 00 'H ^ §3 2ia to 'C ^ « p2 S 1o PrP '-' P P O ' c P g §« ^ /3 P 1.^ Q.^ ^ 5 S w (5 S ■ "p ^ ^ ^ *3 %U »l =1 V . '3 p . 0<'A^<0 p « o P S I ^cf a *"^^5 "p fc.p 8 ^23 Ci to ;;=; > 5^ 2 pp o i-« K a ■1^ P3^ c .5 t: .2 ® be 0 ^ S C 5 pH fl s 3 s < <; p4 ^ Pi < < < iiessee bomban ENGAGEMENTS AND BATTLES. XLV •3 >• 1 6 < i pH I ai d c5 -r 6 < I or ■3 l> pr I .5 I 6 6 aj t Killed and XLVT CHRONOLOGICAL SUMMARY OF ^ O j K S . =e-° CS O a > J o 1^2 'rt £3 rt '«5 '•B 5 fl ^ «.-i U o o -2 ^ S t 3 w ■ ' ^ ^ f-i O nS -3 ® § ^ 5 w r ‘ ti &« . ■ g.-o ■c S lu « S& IS^pa^i 4> c aO C ■“ J 'A^ S ■•1: ^ o C3 CU 3 © SK S-«! a . a re Cci 6^ 6 | (/j« o 6 1^ ^ ^ C3 b4 ►S p 55 V >o <3 >-• ^ © © ^9 :3 c3 ptH.^ ^ >H ■£« •■^ «*-i tJ o o a Qi 3 © 02 02 0 Q w 55 0 0 ■5uissijM t'. • T3' (N - 1 150* 0 •pdpuno^\ 200 30 1 c^ 00 is: : ■p»nra 100 13 10 Ci C< 35 tr C^ (M • 03 UNION LOSS. •Sutsstj^ 24 3 43 TP i C^ f-H ‘ ■ 03 rH • Ci ; 'papuno^ 7 225 4 n n 3 14 3 1 31 70 27 5 •pailiN Ci n-i lO TP 1 12 1 3 10 30 18 P t5 M •3 3 ^ .3 2 a 3 a > aO -§g So| ^2.§> ”-3M S i- ■ 2 .3 ^ a SCS 5 0.2 tlD ii ^ -2 a oD (c 'a a Cr' a. 9 5'^-a >; L'^ - 9 o •a « bS "I ?W 5^6k ■?. S 2-a -3 a g| a g S rt a © '© S .Ti 0^5 p- «2 a o 3 50 *0 a< .> CC '3 '3 irB . a § ^ w a ^ X'S I !z;^Q« .9 J3 jp b^ © 3 ? © ^ .9 ci ci j: 3 o 33 « '2 3-» 3 a a 2 co^ o a ■§ •a'-? g 3 3 o bo G'^ c 3 ^ - © "o © 5 ^ 5 >^q > ^ ci 2 2 1-1 © P-. 3 5 ^ 58*3 CO Q 1 §•3 3 o u © 3 to 3 'a . ’C 5.2 « 02 Mb ^B .3 2'3 m 3 w 3 3 « ^ b '-a •3^ C? a ^ • 03 .a 55 o 5 "p^ 5 ^ C5 >> C D 33 © a I 02 © i S g» P» ENGAGEMENTS AND BATTLES. XLVTI >^9 C ^ C c a: a z-s 5 S’ ^ o a> ^ § ^ o S o c3 Ch a o Im O s .25 Ss^ C c 3 ;S 'S c o a ^5 O CUV* ? ^ . S' S c -2 • 3 .2 CKffi hJ q is o C3 & 3 0) i« < ■g& |3 cuO X rj c 3 ecc § O O < s ^1 «l ■S> < §£ -■■ 4,0’^ S § 0 :2^t s ll cn ^ 3 ^3 ■*r »“** © g«3 p >» © 2 K3^ .2 , c,vh c-° !>.-e-^ b .2 © a X. a o c 3 cu . • "5 3 0^ fcX)-- cn^ DC Q i-2-;-a 2 c3 4) sSS ^ «M Sm O 0 ^ "3 2 3 § ^ rK 3 9 rt ^ < <•£; *0 oS 1 la Sr g^S, ■C .3 -3 ST O « ■^_: ^co a ^ Co 3 .3 O .9 5 a •gr. •§ b£VN ^ 'E 3 © CS Q > 3 '3 .3 3 a.3 m 3 32 "s mT"^ § 2- 3“^ fO 5 TJ S'H 'J* 3 3 g . 2*2 S •o ^ >. i 3 S 3.^ 3 ^ M 3 t4 -3 3 3 So „csh>- 3 t> o '“'2 ^ 3 O 3 >• . 00 ^ c/ fl 'd § ^* esc '^00 a^s giSC ’^'5*2 33.3 Ph-§ fe ^ d © 5S^5 a -I ,.3 p. *3 *& ^ g 2 “ © © Pnii .3 » gfe 'S 3< .3 o ^ ’C -Ji 3 2 © rH ’C ^ 5 C .3 a - W J3 ;2£'S 9'® .^r9 •a 9 1^'!^ 3 3 .. 3 .2 O BO a-^' 3 (» © O =^3 W TT Q OO Ci PhJm g g ^ &c S |i-2lb i S L> S "2 o «s 3"^ 'O'cSo Oi a 42 2 S’?*! *^33^0 ?5Pm 3 w g, 'l.'d 3 '3 a ^ CO kS 3 5 43 qO ^ S?i 3 V bo 3 || *3 o 3 © s ^ la iS ?- f f 3 -c 3 3 © 3 © s 3 ;a 3 ‘s & © bo > 3* 6: ©" bo 3 P 0 c 3 « •g ? © £ g :2; -c- 3 & I I* ffi > O bo n .2 *M w © - ;2 £ 3 o « H > t o PS 3 2 d5 >» 3 .d 5 5 .d . 00 5 C<0^ 5 5 \- Killed, wounded, and missing. t Killed and wounded. XLVIII CHKONOLOGICAL SUMMAEY OF "t? i ® r/" ® 4. *A 01 5 ^ 5 § 6-0. g S 5-0 a S o 0- 5W 'A U . E S !S - - S.^ So='-= «5 Joo°Hj 2of^2 >-: ! 4; ct s ~ s- '■ r r I , S“'CC O c oj be a e L , i,A c S bco C; c . = S -c s Ji ^ E 5 P- . S ® ® MO O ofiH Of^ a. t- r« S ^ ^ C.i ^ & ! *-> I .5p rs aj ® OP s fcD'tJ « g ^ 2 P-< -2 ® £ O " B '2 fcibo 5 I ^-3 rt O; ^ S « r. CiJ H C ■gl “i 1 £ 2 o £ « N® S 2 S C S ea;<» 3 „ C . • CD 6 J c !5 = • I o bS ■ B c3<; , CC fa -3 h. '•-•-Ifa 6 0-5 = B:-^g§ ^ fc S^O o ! s , . .2 fe E.g'g ® y, « 5 O ^ C ® C tM P < cHM 4 C- ^ cS^ U^'pe 2 'C ^ iS rt ” c:; . +j-<«5 c c ^ O .« «5- ^ ^ ® M hj S C ® P* ^ f. o c ^ o ^.■c 43 n £1.3 g J ^ S ® e •— +- • O cs ® s- C ^ ® C rt C3 C [£ ® c-fa fa 1: X •Suissii\[ ‘popano^\^ •P^>IU3 •Saissii\[ •p3panoA\ •P^IIIH r-ja 2 .tiX-B J s H o CS p O 03 30 a § o± •b *3 t> a as cS 03 Q« ce o *£ 3 go ,x> “ I . I S fa 2*5 EC §i s-s 5 ^ si © fa a - J3 a c 4^ a PQ 'Sra.S CO CO P t- C3 c3 © X a g 1^ - "3 S.--a ' 3 ^ ^ o ® o ^ 3 .mO SjX « ^ '.o P lS - fl O J3 © >.5fa ;S^'c5 ^ -r^ .P • sa § b 10 LO © 5 a M a -5 TJ ^ a 2 A b£P 3 ^ *0 >■ 0 « S so^ i-O h» ^ -O'fj'd a - _ oj a ^ 00 - m'C a aj fa 2 “-S «5| P l«H C3 IS’-S 5>1« 2 a^. ^30 'P 'he'd a.t: p p ;> p O3 • -P O a a^ ^ C 3 ^ 'd 9 ► s|« --a “ ■|S‘g . 3" p « C ■§ -d 3 > P P :d ^ P -C p O p p a © S-* ^ P a r;? bD © >» © © 'd p a d p ENGAGEMENTvS AND BATTLES XLTX * t? % s Co ^ K o a ® ® 9 « « ^a: g-c-ffi K C - c '3 a o C ^ w . -^ c ? a a: « f;;^< ■ . .a ^5 tJ 0^0! ^.t; c.»> d o a be a a< , a 5 «<:m 2 <"< s o P5^ I ci £ >- O CJ «s ^ c §H i ^ « H fcx) ^ a£ hJ 3 s a l§ psl e« o o — ■ b* ”|S i” i -o" P ” g i-'5 c K a 'C a «:■ S ££ i; D ° g ^ “ 2 s "d o ■2 »h“ .°^' - « a 25 = |-E^ V *a o ^ "t: 5 i 3s = £■' S2 ■= . “ b ■cljs-s'-gl § S-?: S g § S . c ^ a c ^ 5 2 c '3 c ^ ^ ^ ^ 2 ® a g iS >■•5 .t: o a'^B ^ a 2 ^ -r o fc£i^ .SxJ « a a a 1-5 faDK-3 .2 J3 C a a a ► o a ^ >• 'a r' a _ a . 5 ^ o © J-. •^3-2 d O a c5 « ^ £t: _ o a 'S i> fco a c3 ® 3W 'SjSoj «■> 2 IS5 35 „ 0 § a « ® S % ^ 'd 1 o^ a2.H 4 ^ a ^ W g) 2 4/ P4 a a g, 2 ^ o 8fri aO a a a o O >» ,0 -d 'd ^ " Q % 3 2 g ^ ea CD *-• 3 4D ^ a 4D 00 1 s II o _ ^ =a a ^ o 2^ a •*■> K -2 b *3 3^ U O d a 'd ^ 'd ►-3 > •s *3 5 1: o O 5ts S t3 5 Vi ^ ;h (m . .a.2..2..2-.2..£.£>?u3 a' «■ a a' a’ a" p ’e <; <, S f!=. S S W £l-; rt ■§ .• US’ >i el S B «tH c . Jn'2r5^ S p 5 I'"® ’w ^ 5 <5^ « p p *P< -h? S-2 Sis' p 'C *'r a'S^-s' = 5G£ O = 5| e fi S ^ >2 «P ^ 'j ^ 2 "p 00 § ct o . ® p ^ p p p i-s « ■Ss § S 2 •o{» >p b.»( ■S.’S OS .5 fc: a c ^ ia§ .2.a|. V Pwii H S ® ’P 3s o.^ « gos c S “I P b 0.2 geo O § •< o o EP • fc’-a •gglg; ^ O f' •p o .P i IfTlI' ^ '-o'^C s' S s o ^ Od ^ ' C5 o Sg t: § p 5 o ® c^'s ^ 0,0 I <5 'p • p 'd , .^2 5w3 fe: 0 pq “o p . I< 001 ■Bd . P C tT ■§1 ^5 O C3 *- P o^ g'a KO 'SB "5 £>< O e.2 HO Pu " gn wj "p p s gg p ^ p s O Q 1 o o 2 ^ P CO fl B P P Opq bJj'o §2 s« p •— • “^ -e -s h'a |5o O % Sp^.sg p J S5 p S'dWfe<5 •Sutssil\[ •papanoAV r* Ci CJ ■T n ci 'v •ijuissii\[ •popimoAV Ci o O lO TJ" CO •p^ma CO O C) O Id o no CD 00 «P Ci i—t Di — < rH CP aj « ti 02 2 2 ?io’c S S ,5 s g g 2«5£o e ia'S« = § S a.^ 20 g;";f £ f^cscs-g o 'B- rt s a' o .° a S S Vg g S"o ftg"g soCi do S'SsS’S-B a oiS B g ^ SfsndicOW ^ bb 0.9 .p ’B <=> S bS ^ ^ cT 5 '§'d*C I §G s'a.. i’g “ O »H o c b B 5 ^ 2(^'C o pq p C 2 p . < g 5 « o £r co'-,^ « ® aC2^,o a § ^ a’ o g 5 g ° a fe .= 5 ^ s ^ Z ^ 0 1 O p" o ? 5 CO v* o o 02 o O <»H © js p p o Is Oh^ gg'^ P ..r p .2 32 3 0^ p. 95^ '3 . "'g >^p 'o w +- £k.§ © CO C3 a g Vi S; > Q jd S S oj i 02 ^ s 2 o 02 5 rw< ^ O P >> T3 « Vi P« R ^ i ® 2^ Oh Q g © P .£3o 'd rO S'? '§1 « a .P O ■*"^ (2 ° ^~g o *5 ‘c p «M >• SdQ •d >». a o o W P a 'o 2 l 2 o • lip Oh t>» O *»H Q bo p vf •a 'Sb Ph "bo p 3 o O > 3 > bo ® a^ ENGAGEMENTS AND BATTLES. <|< d® » j ”3 '§ C5.H g. , t£0 cc 5 P 5 .CO — "!§a ^ c §“ o< O OJ o o a ° ^-6 g ^ S 2 > -d rd 3 ii K CQ 'o > "o M < • « SK-s .2 d ,-P ay ss^s S « O P ® P O C p o p © © P © o s •2 d o o >>■£ “ ^J56 & o c 3 p .2 .2 c .2 p ® 1^-. P J> PiO^ Ip Ip i«w >-5 < O o C O LO (P o rH CO .j E c - _• a a> rS ♦* C goK &S1 «a“ t; 5 s fe .2 o o CJ C;- O o't 1 1 S V S m .2 a> iJ V C4-. a O 3 v-cc c . -O ^ 0) g « ^ Pi 1 P'^ 1^ %'o ® P ^P ^1 %> tg ■as < o ,H to .iS is ^ *2 [p "o S a P Pi e?? e® ’© a >2 o o o O 2 H-2 ^ >2; 3>2 '2 *t 'd t? a a> a s *5 *3 c > •PJ a ci O !>^ § "i'-s 5* !n I ° .|.|S ^ ®? rt c <• rs ^ c •a fl CJ M « a ;S^J ?5 w i-> {-I o 9< 9 .pt: !3 ■a 3 £ S Sg =3 C :!; - ^ 1^ 'd ^ r ^ jj go » 'S.tS CS rH •of^ g O CO ^ c3 ® I <0 So >* £P > a» >s s ^ S p 0 a o % o d S‘| 'c! a CO a> rt'd^g ^55 5^ ii 05 S ? tc > ® .2 T> p p o 5 o n S If *|p 5 d: cs O 05 A ^ p o i*’ s rS p p © 2 p* P o n s o p t S o .2 S If p .2 h- 9 J If •a^ ^ i O Q O o p > o o p 0*3 o c ® .52 2^ p. 2 2 p o p Ci CO >» >. t 3 £ 5 5 ^ o 5 C O ^ r-i 05 r-( fH rH ^ ^ ^ ^ •~Z •‘i s ^WV£liSITY OF ILLINOIS, LiKtARY * Killed, wounded, and missing. f Killed and wounded. J Wounded and missing. LII CHEONOLOGICAL SUMMAEY OF w c M 2 'H •- 1-^ a ° =< -s'-cEP cf cB5 • p 2 ^ o o ^ « °-^a5 K" T- — . ubo 2 o a . - K ,'§ •S •«/?£“ o '5 S 3 IS G C O •5cc Co* CO o O > t: -5 U OP < .'::3 *rt K . c o O 5 3 p ^ H u D >> o O rt d 3 &h o . *5* a O) K HO ® OL) •— ' Oi o Pi < -SJ 2 a> K C b0 O -si b O S ti ■•2 a < S ^ V U '-'o . a> 'S 9 |m o •Suissix\[ •papunoj^V ■psiIIH •Saisstj^ ■papunoA^. •p^ira lb c3 » i 6 B? CZ C ?» 0 o C3 rt 1 &•! 0 a c w 55 F.t- I'S I'S o p o o cO 5 O O S > « t 'Sn hi >» a = p 2 o z3 E? £* rt rt O O c3 c5 •o .2 p .9 = h o .- go O F^ ■ S-C o 3 c o o S 4) .- fC ^ § c* §*? *0.2 C *fS 3 2 g 8 a O o ii § > (>. W h ■gm H -s § 9 Q .9 ” a 2 a 'A U § t- I §3 a •C < P^ htt » = .t: S ,2 h S « S «£ -2 rt ^ ^ S S cj ^ *2 bJ s fe s O U fri I § PQ m cT I o •s O psi o u 'I' .i3. P> O tt C< Ci fP . ^•o Jo - as •“ o t.-o“D § Mg' BS I Is-a Sa pM -e ^ cr ^ p 5 ^ *-■ Q a) © '^ a &lpl I ■3 o o ■ a ap o i-s H < •03 < i°-^‘ il.2 -|S e S - ^542 e g >» « 'd 3 S §3 © ,o a cn © © O « o ® e*H «S ® w e «2 -2 . o'S 5 O &^2 :k 511- •§.c 1 s o ^ 2 B .s 2 p.d a g 23 i3 yj C3 p c3 "d '5* a < ^ . 2 - d 2 0 © © Sfl .ix: © fl © ’p d a, a 0 HH 2 s a.S d d g’p, P d is § P 'd M 0 © *« 8 ^ t-H 0 0 d § 3 “ •d Cb 1— 1 H « 0 5 I ^ ■3 2 s © ^ I p 'o 2 ^ d a p o a ® S 'd S "S 5 o ” ^ •C fl" ^ © o .^•■ b ae ^ ©r 1 S 5£ o ^ S c3 ^ m 13 e ^ =i p © 'o t. © 1 - to O H K5 5 '"2 -5 ? ” > ^ S o s d ^ 2 O @1 .3 »P ^ § © « fcl - a --E 5« >» _,p fcX)r> » ^ -e © X S'S js P © > c 3 d ©^ g d 'd S P3 ^ 53 c p a d d « E ” a 2 O .2 ® P , ra 2 p a o'C d > p» P d> H & o IP ^1 w ^ 'Jh P S-S o 0.55 g o £ S K Q 2 " o 'S.”^ P © P 2^ ■C 5h » to rd ♦- to s p 5 2 p o ^ 0 ® d •a ^ -c © © § ^ s .3 o 3 3 3 - o L* o to 3 •S 2 "S K 3 ;a to , fco I? .b a ^ o S “ 1^. I •g g o I 1 P bo o| p 6 33 •e>H S-g K I V d pp A A A •d A A 'd 'd 'd A .d pp pp' P3 pp pp pp 00 c< 0 ct c« Ci 0 f-H 75 Cl ct 75 75 75 75 ip 53 3 3 ?% •d .b •d to to to to to to to to to to to i> '-i -i •“5 < ■< < < < < Killed, wounded, and missing. LIV CHEONOLOGICAL SUMMARY OF •3 ® SgS O S .2 .2 « P 4 C O fl ^ ^ fcCT 3 g O •?? «S ^ § 'C O p G<«sSc'd "s-" ^ .2 c S •■■ o rt S & 2 • '2 « ^ ;cpj =^c tcgoo^ ^ ^ r . 3 o S w S rt-^CC*^ 55 vT^.'tS §w . ^iiSa pa ^5 . -oSirop •■3 So"'g^'=cccg§ « oS^ncrjcc*? -eg’ »| (^ .••§ . £:£ 5; CO «P=- 3 ' 3 -| ° 0='3 c^flc»rtaj®5 C 00 '^Cil 3 »— O £; o O O § O a p C3 o V o "fcc .9 <5 •SuiSS 0 \I •popuno^W^ 0 0 Cl 1,047 0 0 00 00 O) 0 n 13 229 00 9 i 90S 0 Cl •Suissij^ 0 0 290 100* 6 312 4 7 347 200 •popuno^V n Cl 099 18 2 156 0 iO CO •poiini n 450 0 ^ fH tH 2 77 3 30 CO Q C < O w OD o o C 4 O P £« M .2 2 . 2 ^ A ^ ca o £ p f i .2 o .a o O w ^ 2 tL 4 ) =C « P cd aJP Q ^3 t a S & o P ca s o .2 H P CO O bo .3 a i ca • a> o Es ^ 'S I < 1 ) p bo P K 'C •p ® d ^ '0 ff 'd ‘5 c .2 '3 'S s ^ sa 0 0 ►5 0 o" e *~5 • . rrHaj <5'3| .2. 1 1 rt' « P ^ a fl .£00 13C5 Sg g o ^ cc I M .2^ « bo o , o O 2 o to 04 O o a> ^ II •CP W tjD o 'B C3 O 'C 8 a o ^ . O' CD ^ S) O ft !^u o s =3 2 ftO C TT 00 O CO Cl a .- e § c“ s eg g .^s 3 C3 U •Is O 1*2 5 c .£3 £• cj 3 ^ ?3 'C 2 c OJ § ^ o 5 - I o Q «« .IS c*r O4 0 c3 c ^ 2 g72 *5 r-^ cS O k . i1 o o (5 C3 I* s O 03 b -c a Cj § o a t-. s <; & O O ci •,2 o o ® c3 a o -3 S O ShJ ^ 3 O 3 •° a ■5, 3 3 •3 E" 2 a g ^ -s I’g I I 3 2 § S' » B o 2 .2 5 2i B U I I” g B « 3- . o rs '-^ .a 02 ta c> « o fcj) O ^ »ii ‘C 5^ - O t/i Y) sfs g.5'1. &© 3 2 ® c ^ fcDrt 'C c3 C oa2 3 0 3 •g’5 SB m .3 W S“ “ S ,2 C M a E.“ B W P M Q 3 a CO .0 .3 5> c> 5 o p 2< I s s 5^ C< Ct to bo bo '3 'd . S5 ?]a ^ »3 5 . bo 5 Cl Cl Cl Cl bp < bn to“ < < " 0 o 1^ Cl Cl Cl Cl Cl bo bo to bo til Killed, wounded, and missing. t Killed and wounded. § Wounded and missing. LVI CIIEONOLOGICAL SUMMARY OF -2- 5 S 2 .2 S I § g go „ <5.2 i^Z. « S 2-2 •r 2 — £"3 Sb 9 ^3 ca -in ’g!2<<'3 -2 O . ^ *3 M n'^&§-og^:| ^■s p.n oO .2 in Esin.fe t- 3' •2 3 s P^nH'3S< II o n<) go o -ao) n 8 , i a ’ S S d g’o s Sd .2 w O 9 .2 K O 'G o eM o g V s § M !•§? K-y>s .S'S o 2 P o a O •i?aissii\[ •popnnoAV 'V^lU'yi •Joaissix\[ •papunoAY •psiUJI O >» ^ 3 .2 O < fee g I'" •2 5 2^ o P a.p .j3 3, g o.2f oO 1 I C3 S CO ♦- o > S P Q O Cm ^ a> << -S O M to .2 zi M-'-S §.2 . 3 Q -i -I «'B a ea G V.Q P 2 > o 2 ^ £ 23 p 8-.^ no ■5’P3«” ^ a p^ 5 - O 'O -M . p's p fc-. *-■ p dj ^3 o 3 G g 12 S S o & .2 i C3 ‘ !-• P CO tH .2 P< 33 -g .2 o n “s 5 .c s 3>, .§>*"•? go o5 _j-.S £• a . 3 Q K u 2 -2 a m -a g 30 ng o o5 S 3 S ^ S CO* P-l ■' g E-o „__w5f 'p^ 2 'P 5 P o 5 ? P s !!2 ^P - n 2 o § I |c rS < a be O O c tSisS HSnnO C3 o coO *0 35 C ^ •g o c2 'O 6 p S 3 ^ p p o C* s o ^ fS 00 P 3 p 3 ■& :: o 31 2 o V o fc: G a 'a to p to <5 ENGAGEMENTS AND BATTLES. LVII gK .2 «J «o t: p o . ^ ‘S.H cj tn O Ch o W t- c iiD p p< o o p p 2 o c P .« > "p >*■ 3 -d £ a rs « u, P5 M S o C5 ■es 3 , CD O O) 'd* •H ® O ^ ‘o C4 S3 4j P .2 P S c3 F3 -i , ■da go o tjj o a 3 w c« 1=1 Ss a bw| rt - iS Q <1^ 5 W tH Q «M o Z a‘S cop Ig^” S' .1 Ph O rt •3-i 2 •S.S B sag o o 25 50 36 C5 25 Oi 100 , CO 45 80 8 LO o ro CO O CO CO 00 CO Ci c* o CO CO CO 11,583 12 CO Oi 10 36 1 6 80 5 O :i 1 15 8 1 o 13 3 80 o h 42 .2 O C3 <= o ^ 55 c ,j:0 .ii .2 G ?? ‘C 5 -d '« Ci a , o Hj o .5 c5 ^ O -'■ -*■ O J* oT.i 55 S a'«S ojG-C »0^ o w - ssa » a-S •fe b" C3 o c32-a>^ r^-cg a a t. I-H p 3 p ^ ^ ^ k.*" ^ SS- Crl ,• C 21 o a b ” s 0 f3 ■5 :;g|2|c ’o ja o .; a^.aist- o 5^S'“' t- = “ Bpa .M 2 a p pp t' S I p 'S S ^ ^ « a _ ’5 OQ C a .2 3 I i « a I & p 2 5 ^ p 3 P o o 55 So 5'5ii •: *3 C.3 O P oQ w a* . 'O C.O o (Ai «: a? oj oj ly: a: 5 5 5? 5 K' ifu % o 5 *8 Killed, wounded, and missing. t Killed and wounded. LVIII CHRONOLOGICAL SUMMARY OF c*o'2 J. G G c <2 c ^bC‘5> pS « c Pro fa 7-K G ^ O o 15 8^3 O 'b « "b a • ii ? O! g £• ffftcE o aJ 'a r S • Spa^ g G D G *3 IJe o o ■^30 - U v^G O a E g oJ G O ■SuissjH . 5 p ■S'-»'l a -S|”'^SS« atnty t(,t: ^ “ A - a •C a g g ,0^5 bj) g «Su |j 2 g S^l c o 5 • a^ o g-l’aJS t; tr.S O 2 £ A •< ® '5 . ^ o "o K ^ c ts pH -T fcti^ ^ G ^ rt .2 G t- P- 'bo » d o cj b b ^ 2^ oS- « o§ gS S p c^'S'aS S »T O « . O .S' O fc:OW>? G ^ 3 i - --E 8 g S^.„- So a© oa|S ^i”.n «r G L> rN ao!>0 *- o — r2 3 f? ^ S SJ ^ 5^ o g eSOO 21^ ^.S rt >»'0 G pK C G ■2 .GO '§2S§ >C2 « « p - ” O Q •s o g..2>g ag p § d SAc §?A g a •a a.s,'^ g "a (2 3 G^G^qG^O o G 52 o 5 G ggu a-o >>£? .ke _ gi=i a o 0 dS -al B a A rV. s,r:<^ ‘^liZfiSg 1-3 1-3 a ...gOfc, 1 1 -sip 35 ^ ® ."G ^ ■ a 2 > 'G „- g E E I o Q ^ Ogg'^HggS --•a glS” II I S O o a o « 1 Q . p-j'9 'o G 2 ? ■go 'E-g* 2^3 rG G ‘c '^3 G d ^ g ffi a ^ a ® g V o< • >> Cl to ® -F G & O O .S3 fS a fl G 2 W '3 S w 5 S 2' o a « a f^ O G r:i S S,a 3^ H . . - p! W c/^ P^ Q W tB ii tc G •c G4 w 'b o Z o* -H < 2 Q r-t o . ■g.'? ENGAGEMENTS AND BATTLES, LIX M O > > > > « « . ^ o is w ^ ^ T5 a; o a p ■§ ^ -2 ^ 0 ) o Iz; « 3 a 3 sc M O P3 sgp o 00 H ■C„- OCT! P,l^ &3 «§ .la I § o E: ” -e c3 ^ c3 § a S> !2 wf' s s .2 „ “ S 3 2 © 3 a"xio p.° boK ,3'2 02.2 -C S p . ioo S p f S£;og •JMK ^ ^ " Sis p’aS'E ijo S.20P0 o 3 ^ log |:>.o "^2 0 • .2 o£S «*-• C73 o a . ve -2 aj-5,o o 0 “ 3 3coK-g 1111 0 19 00 Qi CO 9 90* 10 39 10 2,102 2,248 400 • 00 CO 280 0 oj a CO CO Cl r-. CO of 10 ! in 30 1 220 35 40 60 C CO CO Cl Ci 40 ■«»• ’-'"N.ZW 00 CO O'. 115 CO Ol TZ <7i 0 0 0 10 12 40 in 80 Ct Cl CJ '"' 00 Ot a •*?* CO 0 50 315 -2 a Q s ^ « i o ^ ^ X ’H < O C3 ^ .'O CO s _rO a s I ■§ b M X o ^==5 C X 0- ej •e=3-= •= 8 )^ (S-oo & f-< a § ^ o *0 .2 i 'Sg © r;3 ts '© g c «2 .fo© aS (x ■«-; O b< g ^KTjlXi W I s b-< t cS tao S ® >sj o c © •2 0 1 «!&•§§ s fc>-E o a w & ^- C5 o . « . O « d g* >» e3 ° S C H o g « a j p p § i o o = ^ B -s' ! a c, * IV >-" § e« C .2 C C © .ec^ H M 5- £ ^ © 'O 0 uT rt 'a ® § tJD « .is 2 S ® P3 *^Z’02 t>. a i-i ■a ^ s ^ ^ 2 53 ,5 < P c © s b . 0.2 P P a: «: cc SI © % oj {» a? w a? aj a? CO © a? O © o © o © © © © c o o o ja ^ ^ »o o o Killed, wounded, and missing. t Killed and wounded. LX CHEONOLOGICAL SUMMARY OF to ■ §"2. s .2 « O w n o £C^o"c> tj- CU © o ?■ o jS-5 . ■«- > I-' © C tS ^ - tc2 © 13 © w C ^ |Sls“l§ &oO-=:h ^3 t: Ci Ci o o •popunoAV 80 1 3,000 •ponoi 1,300 11 UNION LOSS. •Saissti\[ 4 489 Oi a o lO CO 15 23 •popuno^Y 1 9 2,943 8 1 13 5 00 •v Qi • CO •panoi 1 5 I 916 G TT Oi rH t** rH ^ M Q H C ? s 'S ■g o ^ o C> o *J- . »^.’G G O G *' .2 r£ § c*. .- C* '^s . c 'G «t: t.< o ZO I fcjo ‘C p g u S c I >* t. »- © •p^ S S §>8 »a s &”8 O cft .. O CL^o •*- c 2 2 qO a & 6 G c3 S« G •G 2 ^ P © >» G ©^ £ S 3 i55 '^ ■‘^ § a S p B B S 'G ■a C* §1 S S SO “I* &2 §a P © §5 ■p C5 o G fe: o G M e ;? >. a fH <5 © .2 o B B ^OPQPPP:^ ;a 'S) p. :i K;2 §-“ s B M c .1 cl o c 3 n e =■« o C .c 'O' < P K P 00 g' & i'p a S ^ 'W &o pj Pg bS «| (— O c 3 ^ P 2 Cm ^ fcD o S a x 01^ r— P 5 S 'd 2 C W 3 ^ C "a o C3 . 5 33 'S p 50 13 P g S P ^ c -d « « 73 c3 C^ t— — ^V, 'S I .£ a >» p-*© ,iS >» t' c 3 d ^ O c 3 > S ^ ‘S « © fa 5 ^ ® t; '^ 73 1 : © c © C cS£h 12 ,-H ^ to c3 ^ »H fc- o a = 1 ^ ^ >p © .“.2 ii 33 'C ..OB sP .Is S'O 3 0 e: o sSo 3 . ■■g g.g> c-Sb §'3 ^ O C B P x! >u 03 K-s-g ■o of a 3 S I 03 o C 5 b* 'S- © oj S^.S C 3 *5 -Tt W|S| P5-o^ lO P ^ t>- C3 W e« O 03 CS £.-S 43 a c3 rt rt 2 O k, £ tH c & o Q fa ^ .£ -c fa fa fcn 3 -- H > be fa fa © o be .3 © .is ^ .2 -S c « p ©” t> - I fe eo a © -5 s i I i I O C fa fa be be > ©'■ < fa e3 ©*£ «c:«r £ ^ c © k* fa Cl Cl Cl ©< O O O O Cl Cl Cl Ci C C O O O O O o o LXII OHEONOLOGICAL SUMMARY OF ca ^ •C be B.S be OH a = s •gO ® HH >■5 .te £ n §i o-s •B A6 rt fe bjD,P *E ^ a . a> 0) C ^ rtO o. . Oi t£) P.S gs O 3 •< o t o 04 o o < •e 1 §■1 ■D IH o o 0) P I o a o 3 P 1 o "C o 04 ■gOJ 2 P P o o C5 <05 p O o p 3. a» .a® ’O'*^ < *3 ^ 0) O ^ K 3 O c o s? 05 a_g « Kl c o p c P .•. "sl ■H O i ^ 04 2 ^ P "eg *5 m *2 '5 !6 *2 'S !2 1 *2 'S £ [2'S} o a £-< 3 .3 a» *2 '5 e ,3 o eport page p ® 3 ^ €< .*2 'C .2 w p (D oi p 3.'a5 (o o ^.O I'S g-d P o c o o O O P o K K o O PS p P CO Cl o ^ » a> t . ® w c £ CD ^ ‘ ^3 £ a txio 2 5 ® c >•£ H ® c o < s cr. c a S eg ® 5^- I « ^ n ^ t a o a « ^ 2 m C C3 ^ P 2 3.2 tLQ 2'® .2 c S « P ‘C »ed •d C eg £ £ ® ' m 00 O £'i C3 fi ££ c < o > a ^ o "gs •eg Bg bo ? >. 5-“ eO -S •dB C£ 4J ‘C «§ -I ed 5 o P eg C>0 S eg eg C p a a s c ^ a jrPP •a b- W £ O ^ §}£ be p a P w? -> 2S bo 3 > fc*.2 O rt p ’S o‘§5 ^ .3 1^ P |l o 5 3 rT* O *3 o 2 £f a •o “rS ^ C CO c m ^ 3 £ £ 5^ J?5 ^ ^ ^z; 5^ 5? :z5 5^ ENGAGEMENTS AND BATTLES. LXTII o fcJD o g .-H CS ~ g§ S C 2 o - a’ > S-9 -r c3 'O 3 S O •rr.P a «3 a a o o S S ^ Ph .—I ^ c; 55 e-s o K O to ■c n <0 « . .a B o 3 » -§ I -d g Ci g rsO S'? 5 55 >» H ti < 3 ^ r75 H i> ■ s a a a q -*- o v. a = 4 as U O < o ^ o -O o-E" .2 b m !>. fco •E PQ C7 00 CO CO t ^ b , O 'd «5 1§ Oua' u rt rt SK '§§ too •EO tt ’'3 P CO S li. S as 5 b CO c» d> Killed, wounded, and missing. 1 Killed and wounded. LXIV CHEONOLOGICAL SUMMAEY OF ^ O ^ a o > I ^. 2 '“ tii BO< < --2 o «> ^ . M ' ^ '"S *- u--£U sc; ^ S:^ « C3 . *3 c3 s*ci a ^ S o ;2 0} cj s S o c s c ^ & = ov c ;fi '3 a; cj Ph< [§CC 'G • go o 2 & 7 ^ c3 e3 rt a © o :3 S .2 o T3’ < i: a © PS 0 . -o Co J- 'C .0 0* J5* © s «2 c‘£ ® iS’l 111 K g § a •3 I g) e S.s o l§l"= "S :j.Io *-©.©" S A e, o trCw ■— © CO 0 2 b © 'c 'G *2 © 3*c 1 ^ 0 ^ 'cii« . ^.SPi “ 0 © SC^cs 5 < o O a to © t: ca 2 C.2 rt s V O x t= I s ■Q gC^'O -5 C <1 ^ o “ e5 o a 0 d I . 3 C ^ .c o . ^ o M4 © • P5 g> © pcs .2 . 0 u 0 E? «'l u C3 15 . *©*< 33 © 0 © V. 2 ® 8 c © 0 a qCO 15^ 0 .d ® 2 6 ^- 6| , G. 0 Foster, 0 i* Ocz? ■S'2 a: _.C >.2 © 0 0 s © 20 *-'d 0 0 io o •Saissii\[ •papano^Y •P^IIIH •SaissijY o CO •papnno^ •p^urH S s ®3 .0 . O . 1% .2 0 r: 'S o © H 'S ^3 0 a s »2 0 00 -2 • n3 c <^ §,• « Ph si 1 > - So 'S >* rs © 2 ^ 0 ’•« 0 o c: 0 © 00 £ O 0 rt :: §n 0 ^ a 0 s 0 rs 0 0 0 0 0 -'S o o C5 t'* "to -0 ^ © I? o« w-i ^ 0 ^ o 00 ^ ■i Hh H-- k 2 2 ’o .2 S .2 'S £§ E5 a§ 10 Ci S to S o ® 0 . 0 ; o o O £■ 0 § O a o ^ 2 ^ §3 Qi ^ .t: •ts o “55 fii to (3, © ► PL( 0 K% ^ i ia |I«|E ^ c go: c” "t; o © *03 .5 % g ^ %°sit ■~ g ‘rr .r ^ o‘P^ .53 0 g3T3 3 H fl ^ 0 >P ot: X 0 ^ 'C Q 0 ^ •c “ « 0J 0 © fco 2 = ( 00 < . i e > 3 ■ 's w 5 ‘Cs 0-2 J I'l © *0 pH CO £■§ S •o 2 S 0 © _ ^ gP^^-oSl g = pps ss'i^'eo; ’g^oS’.s. © ^ 0 ' t- ^ _2 2 X -^ •-' .|.>L-^:2g“° 0 r- © ^ > 0 g a .a S ^ » g s a: V- ° g-ccc^^ oO’g cs^ 0 ‘jp 0 ^ tC 30 ®'-®-aRC® r-i® grtO ci-10rt»^0 -l^l © -*- c< u o '§ 2 0 0 0 04 O © |fi S o |s 03 *2 «w . , 0. O I ;-> ‘S’-’ > o 0 fet- 1 0 's3 3 § © S is 0 ^ S a -=’ > 2 0 0 Q rS’^ O.jS S ^ s s © -s \'!^S 5;0? >» © 'd © © c ^1 1 55 j: 'd © ra ^ toCi •3 0 is s'" .0 H -0 - ^ b e ^ ^ © 0 '0 3 o*- t: -0 '0 .Hf* 5 ira te^ O ^©-g ^ ©■So i3 ►?'§ b *5 © tft S ji5 j: '0 txi 2 0 go o o 55 0 “ o •& c a Q Q Q P Q Q ENGAGEMENTS AND BATTLES. LXV -■'Z '£■’3 8 A o s 0=2 ^ § "t;.? >-.U ” c "C . W H H H o fo. O to 03 «M c3 ® s t, a o < cO o 'd .2.0 <; K « CO -*- e 5 O'® o.ti a a rt a > B O e| ^-T O yp. -3.: >» s 1 ® 5 o CO Ci '9 c3 P fciJ) C3 ^ c3 .s irj ^ .CD c c .=: : - O Ci.O p o ^ SO s § ‘aB a « iJ C G CO 'tJ '§ CO .li S'M O Q o r. c o a> ’O o ^ to •O 2 .®.G C “1^ 'S >'d o g 3 o 'O ^ 'd o M G g »“ a § *"g CO 8 'd o G d g:g bog P *?,3 j o o,^ o G o § § go 3 2 5 S c P o S g: „co SI O^jJ^ 2 G - S 9 L®to2 2,0 = “ 'u^ rt 5 "a o 2 O g > ® G 'S.. go ? t;B o o ft ^ g" *§, fS "G 5 2 S -G ai ^ O 'to n p 9 =3 .a to a - p 1 's & 'C ft •2 § S (l> JG H ft ft Cl Cl Cl Cl Cl § Wounded and missing. LXVI CHKONOLOGICAL SUMMAEY OB' ^ . 9 D oj ft •• bn ^ 2 M M P uT"^ N pH rt tS 2 ^ ja 9 5 ^|S 1 "S 5^|Sl - .-C o o.'c 5 o n. . ^ ^ >» © p •*-— ^=— 'Ud 513 OS’* -.2 5 =-•^'“-•2 ® S S CC ® g ,K- £ 3 - 2 -3 2 llJl'S “■&" g|®'S 3 3 20 s'2 3 3 “"= go a I >1 p I 2 2 « a § -3 'S P ra H ;h P P g S<;pa.SKQ o .3 :=3 a p p » S . a t> O Mg —• o p ^ « p .’P (S”| c W o ^ a s s fe ogP ^ ^ o, 9 . o 0 « t-i o © © H •-4 p a P bO.S © *c 3 {gnM o bj} bD Ph > > > > .®Q cr Mg 0*5 w'P x:< ^p 3 2 PSpj OjS CjS o 40 o • O CO 1 ^ • i • « « rH t • ♦ t > : S ^ : ■ o • o . iO“ •papunoAi •P^UTH •SaTSSij\[ •papano^ n T^UIH ® a s J. ®> p © 03 -g _ © o o. bo ^p p M g s P bo g« o ® o > M © t/i >%2 © A "p a g § S A - Ui .^•r rt* .2 p PS© o Ip bo^M M •== > O -"•g bol M® a o g s '”'§'3 o g|2 'aJ >» •r^ ^-*2 ’Pm? «P w g ® ^ a m « p'J p|3-a PO?i! Sig^ . © GOA<«h . © O .9 ^ >» H c *3 C3 M > 5 .2 O ^ bo og V 3 .2 ■6 s 1 1 1 i“'l © . >^3 St; ^'5 o 5 HH O S §1 §og © M bo . ^ p o<^ «3 'c? e-a . O'S III 0 §3 j- «<« a «« o g §s; £>-3 f-a g § 1 §■< S' H !&■ o a >^■3 .2P3 o ^ ;p ° -a b «*§ fe: § : «r -2 i M OT-Q :>i=s s p p O ? p M w ■' ^ J3 rt 0 3 0 > 5 e'bb-S §3rtSw ISMp S P p 2 ► _ 0 9 p -a a I I ■p- 3 ° B < > o > H ^ g ^ a •« eg £ « d a o « ^ M < <; K C « O 5 a o« P< Af ’O • S®* 82 a 16th to 22d. ENGAGEMENTS AND BATTLES, LXVII E,o « < S 2 p;zi aV 3 - G i 2 . . v3 ra 0 ;=^ p p 3 3 &;•§ Cm O be P ta *§ < 3 .3 . *- .*9 0 ^ 3 p -e 3 c ^ » c ? I 5 p< m" P fl K (3 P 0 « "bo a 3 [3 .*9 s .9 is is is P 3 e a .a 3 'v m 0 a 3 a a 0 0 0 P 0 0 0 0 100 300 42 CO 130 600 95 100 CO 34 50 12 20 400 Cl 224 12 1 GO 0 QO HT - 50 35 6 49 80 j 23 0 <£> pH Cl Qi ^ ■«J* Cl rr rH i£> pH c O O >» S o , M .i ' '2 C a ^ c3 > (H 5 =* sp ® 55 c; &■ §i O *3 a> o a *a o 2'S o g o o pk « .3 g'l OJ ^ C PM ^ rt O 2 ^ 3 3 ^ w ^ ^ (D w . It: 2 ® : « 9 m *3 J3 ® I o ^ ® , « J-1 c o p p o o ^ o >> sc ■s2 <«S( o .pc^ £ 's ^ o 51-3 ^ lo S a 3 3 '3 Ph ^ g • ';i-2.p i“t gg 3 mI" ^.s'S r9 52'® ♦- p fl ill O) 3 ^■rJ ^ 'I §o S .9 0 .9 C 3 ^ O Q •c c ■- ! ^ M tJ , fc 4) H a o •Eb O P »H &( Q P S H ^ p o o fi fcj? ^ a o H S ^ hJ »H '® .9 PQ ,3 .3 S O 1rt tft *3 Killed, wounded, and missing. f Killed and wounded. LXVIII CHKONOLOGICAL SUMMARY OF be a, « O tgu o 'A O ■SdissiH •papunoAV ■pama •3aisstn •papnno M •pama to a '3 a -3 1; c »- o k K* a w © 3 « ii S o bo ^ a ^ . O i'i 'I O fe 1§ & o O •c o i f cS rt ^ 5 ^ 3 s ^ © O -2 ?_ © o cc _, c 2 C* £ "S ;p ^ p o a © OJ o ,ZJ c 3 o o M o si* ■gl rt CC © f-< © ci m £ efi rrt 'O §1 a S' CO «2 r§ Ag i S g E Uo S 8 O '5 .H -P S-2 5 rt © P« ■so e c3 I s |i ",i « £ o« g§ “£• o .2 ^ £ , “ P © rP Q M © P e3 P e «2 . a 03 O 3? & rt ffi S ^ - C3 S S "2 .2 'o iH o ’£ P3 P O O « f .o < K t-i (ti B O » o o > s I .5 ■I o c = 3 =2 6k OSbl -V IW SsZr Wl slP ^Slb; I -3 II I c •i 1 Ch b ! I i' I i 3 w I a > I I § I s s i i I i g 5^ .. s. I I I .1 I I II 5 I i i I 1° I I s s I I S 55 I I I I I I I I I LXX CHRONOLOGICAL SUMMARY OF o a H Ph a a a a Q c 05 M a < s a a o OD n U c3 a S 3 o a ^ a H S ^ S a S o ^ a g s &B «g, o CO "B B !-l oa '9 r:i o S eS o S OS . V .5 <: 2 £p s 1 “ I ^ d ^ O a o u to 2*0 *.| sa« a o a o « a 5 <— • B<: "o . % a ft's ^ o (« s -2 1 I s o <3rH- c CO b fer ^ S • o ^ i? v fi OP <3 Ora b< c O 0 •«' O £'« o « a E..y> O so o bO/U .e3 ^oo •JSaissiK •paptmo^Vi^ •p^uis •Saissrj^ •papunoAV »0 CO •P^IIIH % ’id a Is _§) s s tg S2 CJ o o O 5 a §3 Ci e3 - bD "tS *-2 O « ^5 * ^ S .5 Cm 0) d «l fl O j> s'" « a ^Q) o . 5 'CP CO « rH .3^5 « •|3 5 rO O a 3) 3 fl O 1 = 52 K" flS •cO >» O > .£ b Cl .S a esr* .I'S *«i; *3 ^O a s > a -S W ? C •°B “ i- o d O' >> fl w’-a So 'S rt •o a >» S^'P SiJ w 2 n 3 rt ^ 2 § .3 3 « >■ ej d ■50 Q *3 ® 9 d S OJ — < ?n H d S r to bo .2 W ’> s a S ”-3 H Q 5 s o o ^ JO CO . »4 . ft n d ^ ft S = <■: •£1 <: \ ENGAGEMENTS AND BATTLES. LXXI TS O p bX) rt 'O £5 tB o p c § ^ c c S c O b fan »*§ ® p . < ^ F-. PS P o ® rt B n O ■6 b CU P V S B a O S5 2 ^ « £ ^■£'5 .14 . p J J f 'i ^ 44 s: p s c< P ^ 5 i 'S rt.§«5 «?H ® . 1.-5^- .2 i § § c c C3 O ® 3 g g/^icc CO 5.2 ^ rt ® . g 2 a« S) £ S p 8 ^ 5 o >* >»p f2 E ? S J3 rt 2 ^ O 4) P C.2 00 X.'’^ p.^ P '3 TJ-S a a a cs .S ■Si « s tH O o .2 •« ^ IS 5 ?' 2 P IH .. o 'ey &C s o #«5 'S ip^ rS P P JS a o [S g *bD o a .a * Eh *3 Q P 5:z; t- o > § » M 5 tj 52 G ■si a §p2 II « .E5 .d p s ii p p c 2 p 3 ^ § ■CO H =1 ^ 5 > 5 M •e: P! .2 .3 O S 4> P •o a |h « «r O P bOP p P 2:3 ^ bo a 3 *« igM 4 ; o S5 35 p 5 p £ 5 O H- P 2 *3 o pP P a> 5’^ P3 5 >■ .2 a .p g, « ‘^-5‘ p p p j © M pq p a> © P 2 g •sH CJ 4 © 5 5'^ 5 p< < 'C « ‘G P.'^ Ch < © < ^ ■« * < 5 * Killed, wounded, and missing. t Killed and wounded. Lxxrr CHEONOLOGTCAL SUMMARY OF •Saissii\[ o ^ bo ^ S o a 5 o £ *-• —V a: ^<3 O oi O rs' < J=0 P o S o. K pr o &. £1 P 1/4 £ •« o fcB m a p.® •po];)anoA\. •P^IIIH •Suissri\[ •p3puno^\Y p p p 5 •“ Sm S _ P 'P JR = pCJ) 8 c Pii P,p'5 Q ® S I © p 5 .S Sr-S P 2/." CJ o Ji-S P © © © s s IJ © Q «4H C . P <= S £ bs!! E-5 S c; P 5 •£ •S - S s ^.2 £ c ”3 « -T* § ^5 d;^ 's X si • cf^ e o .§•§ (h C > l |5 3115 1 .2 g -C g C I’S'C .2 5 S V Q C o .-. '^3 rsli r. 3 '35 -- i - 3 c 3 n ^ ^ =3 ^ cfi '35 - .'& fci-rS § § _,Q g JS ? - ^ 3 o ,§ '*^ O'S C rt,- c ^ ^ Ph .-g .£ rt & C 2 ot:.^ « u s'si.sil ° g C.i2 ■=■■£.-" g,^ c o 2 2 n 2 5 a c e3 cb c. r"! ;3 ...2 o c^ t' o t! fen •c >» •B< t-J «2'E 2- C P-Jg o< O '35-t- 'P'rt 2 c >-■ .2 C3 k. ■Sa .2 §''2 C CJ -2 t3.i: g “ S) w' ips a S^a o 10 l>» Cl 0 0 r-< GOT Cl cc 50 60 rH V5 • 0 0 If Cl * • • ^ 00 — • 0 «o 69 5 6 54 11 20 <0 12 1 1 26 Cl CO 1 Militia Cavalry, 32d U and I.«, 1st Missouri by Brigadier General Watkins olunteers, SOth Illinois npanies of the 1st Ala- Jolonel A. D. Straight, tomac, Major General ftd hv Cantain F. N. rolina, commanded by commanded by Major gadier General John rk, Cth West Virginia, dound City, Pittsburg, jtte. y, 2d l\Iissouri Militia, jht Artillery, of Brig- anded by Lieutenant 51st and 73d Indiana ama Cavalry. ijor General Sherman. . 5 s-s w -S C3 ^ =3 ^ ^ s g 5 B «r - s ^ C5 O U .2 — .2 "c r 2 'S Il* C3 ^42 .1 ll i ‘ c 2 c '33 5 i f2 c2 ? O >-' _* 2 ®3 0 o-g «g ^ .2 c -3 5 1 gll» is P c3 2 4 iS 5 2-3 B p fl g W-2 t: i: & a ■eg 5 g c 2 c ^2 “ 'c g ‘Sb § II 4) ■a S d •r" o ■a'-l ..; S-s O o ,o g,» « o~-~ Sn ° 3 (:a O 3 ^1 330 g PS bo 4=5 a bo.2 s bo •sb ■a I S §J ©■a <1:5 -d - a4c C3 « w © 3 © O'C pWJ d ©. d <; « CO .- 4 i ^ c 10 * Killed, ■wounded, and missing. t Killed and wounded. § Wounded and missing. LX XIV CHRONOLOGICAL SUMMARY OF •Suissii\[ >■..5 tD? .i ® ; ^ ; Cl 77 ^ S c ^ ^ C ^ tn^ tC r: ** « Sg C.5 C-- t- a S 9”r3 c c 'S c «.2 b'^'d ^ 2^ C « C rt '5 c3 2 M - c tn*' . C C S cCS ^ .2^’^ ^ c 3 ar»p H 2S.£— C 3 ^ 'd “ g -2 a c — * . bt "" C'.g :H'-i a H CO .2 3 Cm « •I t 2 2 §*2 S c S'* CO_r I < £.= -rf •3 2 C3 O ^ |S " e -H 3 • K 'C a CO ' 2. • c w' ® c ^5 c 3 , O . w ^ ^ < Q ‘-‘t — J2 2 »-J rt'c 2 >-3 3 e1I|I o tx» ;®|.= i| i J rtS C3 O o ® “I 3 CO ^C- 3 O :^s '-3 ■es O C &Q rt « C 2 o .2 .2 2 33 e3 cj ej P K •papunoAV •p^tUH *Jdaissi)\[ •popunoAV •P»ll!3 |2co •o' §5 §«s egs o'lo S » .2. . d.5^ c sa E a S a 0)^ o Sp r'S'S « O 0) g s s a •!>“§ S^a w ■**' 2 I'si O ® ?? ^ o CU ^;k « O 4 J 23-; fl ii ^ W 3 .3'^ -Jg ^ CO a i.2.a6>^ O re?c CqS go .'3 -"S p.t. 2__ g w •*" ^ o ^ 2 ^ ja o .2> a g g PS c- O 3 0^ s 3 S ^ S O c 2 P _f- ^ C O £'il« « go " K §£ o' .0 S O 2 tnw I ^^|.f pii 2Q““"|o| «Sx|S£'3S t- 4> W ^ <• .2,0„ .W’; all^l - I i 0 -0 2-^1 s'2 " &.2.§i^ f §.2. 3 3 0) C O CD BugOi^Hlaaa [4 :e^ “ H J> 2'So‘ < 2 oPh a . S(» Ik Og J3 *• M 0 ) 0 ) '^‘o g 3 3 ^ 33:0 •d “^ »-• '^^js 2 •aS-g §-.S> SC'S® P«S 3 >» C -iK ^ S.2 3 5*3 C O C W.:1 “'■§ I .-3 § |g8 c C i; d'S 3 *3 CO E £* c '3 2 « II 55 -5 o d 00 3 3 ^ 3 Cs 2 3 s d ^ 3 d & o O 3 ^ > K ‘2 ^ c rf3 > .2 d 3 t- o p> g ^ O tS ^ c; c< ^ ^ a n >. “1 3.2 c^.a 5.^ §> to £? ? £? > > 3 .5 •“ H « O g a -' 1 =■ w la § !i a !E ENGAGEMENTS AND BATTLES. LXXV 3 S SO 5 ” 3 2^ «•- s S < g *o< t: ^05 Cm o ^6 §5 K . O ; r— CO 5* „ ^ s >— 2 ^ s ¥3 a -g-S a «! >>s> E: „ a S a § ««!§>§ S^O — •^ • rt fl ^ ^?5 bDb0‘ C8 M- g-S '^60 6 a If c3 *j c3 ^ 3 p-u «o c ® ® 3 c rt 15121 a, Q O o O < o3 o3 coO % § ^ E s V o %yo 0.2* ^1 si s « o >,ri A t;, 1*3 -f^ U s CO «3 ^ 'tt c^ c .'S fli o £« §,g> 2- aa a ■“ M ■q a tr'a O-S”' a •a.« ® a casS'.- a a a a a e.H a |a°o 5'^ bgj ^ O o ta" • "S ■cO= 3 a ^ • cs c; S . .1 t* •■:: 3 rt 3 *3 0 '3 O g .55 S’ o rt®*® ro bo a S .. 25 C 3 c s;. ® 2 § S- '3 a 525 ^4^ 0 r i: g ^ c 3 s ® — s b 4) i2 3 ft fi 0-0 c ^ ” “ .2 " P- a g ^ cc ^ 5 c” O li ^ /« 1 g>l « 2 3 Is e.5^-a:sW^c: O 5 i.2 = § £ £ § " |5 —■ a a a W jS gcog ..SJ Ca»“Sf ~ a o'^cats 2 S 2 S)'i (i- .2 ,a a ^ a O ^ Ch C a a o O k3 .SP .2,5 a a X o S* « •.a'3-^ I - a5 Si S ® 2 rt ft o M3 'i'^ I' 1.1 S ..20 KgpOS M «f 56 «-s •5 bo 3 . ^ 3 ® .5 A2 CO ‘Sena O = < bg ^ o cj o >» g s •Cft «s . M *3 a> ^ -3 ^ *3 O a cs g§ ii.a OCO S .2 2?- r* ►4 2 «> rs o E ' a> O I g Ih i C.&: .5 a ft 0 b S 3 >1 * 3 *=!^ a - s *3 a &P 5 k 43 3 bo 0 PH iP 2 *3 4) Oft E'-a a 3 > « 5 3 ^ eg 5 § 3 © b © § M AS © © 3 © ©PP h • 5*^ «lo rt S i. 5^ 0 C'C-'S' a a S-s*’ .2 a a. j3 a 0 0 ft H s n 2 O . °s o g O cS o s ^g I -I Is 3 a c ci E S 0) .3 5 pH a 5 t. 3 . 4J D >. go a 0^5 o'S-^ §:Ze '3 rt 5 S ^5 1 o3 g J3 §0 S flj giS.2. ai&<5 a,^'^ g aa. g a o 03 I 5 I I ■« -3 6 3 § a 3 a •C 2 la- § ^ •is .2 p- ^ a 5 O 3 C> Q OJ 3 ^ ’° 2 3 3 > V u ■& "^6 5 3 oPh .3 IH ♦- (U S' S'^i M M «w O = 0 § o ll ■i« ^2 -i 3 ^ V go o . ^ = « .x» O o S& - o ao O J 3 3 j^ O 5 V Q 3 0) § s " H 3 *.3«2 ^ H ^3 3 - O g 2 o 2 £3 s o j., “ -l^l .b 5 o « S3 CO 3 3 o § 3 ■-& K ^ c ■s S 2 3 a. 2 Cl ^ ft 43 oH U a 43 O V. >> •I S .3 <>• H<5 *3 1 ^ •I S'S .2 43 g .5:5 2 '3 oO 5 ^ •3 ?3 M o O 3 3 -§5-. 3 ^4 03 O 3 'h’^'i 3-^ fl .3 .2 *& > 'd A3 2 «9 3 >. J 3 ■c — <;2 3 "w 2 ft 2 o 3 o Ld *3^ ^-3 43 5 .3 ^ .t! 'o oU |cc 3 kA s? A 3 A 3 .2 S 3 I I ft 3 a i3 3; to r3 rt > a: 2 r 3 3 o o H ia“ > © 'Af © © a c ft P 0 3 0 © ft A 3 © 0 'ft ‘S4 a 3 ft ft ’C 3 A 3 b © bo 0 0 ft ft J-% 43 5 5 io5 ^ pH rH >» >»'3 3 3 3 3 ?. 3 S =5 35 C9 a a * Ivilled, wounded, and missing. t Killed and wounded. LXXVI CHRONOLOGICAL SUMMARY OF o c3 c 73 tc -r i -7 ^ ^ c : c S ’3 •"=5 2 O C-S rto- g ' S 73 o .55 c o ^*2 fc S ‘ S ^ ^ ^ ^ i ! 2 «2 . r? S , O ^ I §d gl fcC ^ fl 5 C; ? , ^ c > li - ” 1> ^ O O ' s5^ " ^ c ' ; « c3 rt (5 1- fcO i i-i ^ gai § i Si; a^' c a ^5 i||l “ 5 o '7 "Sig-g 'C C-"^ I 0--M ' &CJ': o 2 2 -^Tno S !rl O O • C C 1 S 4^ C I OC-C I y . 5:5 iCs^Sl 5 "S bo &;§ ^ § - s li o •5 ^ S.2 O P5> a!^ o «4H O o 00 « o ^ •3uisstj\[ •papuuoAV •painn •Saissii\[ •papauo^VV •p^iux ' ° s s ^ § g “ o g £ r « M ; 3*' « ^'3 ^ *3 . ^h”|I grs a rtS-^ § 2 A o ' ' " ^ ^ fe 6-1^ “I C5 >a S-; c p S ^ f3 ®-i 2 > c . ;;3 O ai «-s1^g — ” t 3 o a J i § "^ fco SS 0-3.2 ;> .i .S SiD a S'S ■P ..^ P< g g r* O . 52 .3 ci & ^ o kS "S' rft ^ '2 ^ 2 ““ '3 wraro>»3S _0+iN3 ir-fg?.! ou^'g- X.g ^ t- O f- c 3 3 Qi S) S £ '3 3 .-S ^ C c -CSSgSgjsa^a.;; >i w ^ o 3 rt t. £ o o £ g - ^ & 3 *3 a. - u vr > o c o,P 2 i rt ® o ‘ ’ Boi a ^ s j cs 30 ■gSg 3 .3 O 'pI S C^ O c3 7 : ‘3S.2» rt ^ 5^ S o u pH « '3 > -3 rt'3 ?=«§ » . 3 B 3 . 3 ^ ^ t->. *7 rr IS CO ^ 3 c i 3 ^ '3 O r>> |5|’3 ^ ^ O 3 ^ ^ ^ CC & o a 3ii 5 0 :P a •3 « £ ^ S 3 ^ bo LO O ‘ji ^ 33 ‘s 3 II ri o -c; 'd d £ . 2 -5 pi -3 0 0 0 rt 0 0 <^0 38 00 10 o 4) O 0 O 3 >» o >03 3 s a . rt « ^ £ ■BS 3 ^ ^0 d W s 3 ■ 3 p'l •“ 0.& 'd 3 b "p ti t:-t= o -* 0 tT B 3 flj " 3.3 3 .2 w 01 03 53 CD ^ CO 0 00 CO * >.3 Q a a a "o fO ^2 cS O cS ENGAGEMEKTS AND BATTLES. LXXVII 55 “S < 3 •3 !> 'Sg II 0,408 : § 200* 200 700 2 10 21 1 400 S 100 r-( • 125 s (2 80* iH 7 25* 1 115 - 2,500 1 223 14 26 1 fH 500 CO O r-\ ^ 154 20 4 f t Killed and LXXVIII CHRONOLOGICAL SUMMARY OF CONFED. LOSS. •Saissjn 100 100* CO 850* 5 100 •pdpntiOAi 600 1 CJ 001 •paiUM CJ 00 • ^ <-H UNION LOSS. *SaTSSij\[ 500* 300 3,000 200 OJ o> rH 00 ■pDpanoAV 0 «•» CO «-( CO CO rj< •paniN lO 10 24 14 >> o § ate to - o-s "1“ w-a <« s K a as O K t, o fu *0 ci bb a a s o o o «§ 's a •11 a « o « «< Od . O a o 3 ^ s.« EM Ci g ^ .S3 3 ° o a a 6 1 o 1° ^ 1 = 5 'S 5 . O C O ^ a 00 2 § ' 3^1 = 1 ^ M &rfii t -S K§t '3 es 'S W Ot: p . o SO O O Q C5 C '/T, H «: O O K H ;« o 5?; D J2 t* O V 4> rS CA P 3 o •'^ •3 = 5 2 = - i 5 ci «5 ■'^'SL 1 C ” " crj c _* ; - J . P 5 I ss->..-o • o $1< Q > ^ ^ ^ *i c « = 2 ^ -^:4 ^ -'0 .s'^.s c a lU C 3 ai L^ •— a ; P 0 Ut "ic< § o >» §1 c ^ w ^ 0 s p 'p p H >> .0 ■g'S ^ 0^0 ^ ca rt ^ r-i 0 ^ ^ 0 l-g g rt£ 1^ g o;3jiS ag t3 >- — «-o t: rt fl 0 . rt C ^ n;; js o 9 . -5iO r'/i p t. ifi : 2 ;« - rt • a t: j .2 p .c 'T PH P ! S'2>' 00 .S5 ! E^'a^-r ’ f.s:> Eg C a ^ c ^ 5 0 ^ 0 2 Ci 'C « ' C -s ?- >. 5 >» • w a _, fc. p t. ioSl» 2 -if^ i:|2 §os •=■3 (3 o 0 " i a "a '3 oaa> |mm a .1? S| s PQ a t rt 0 •?P? .2 c S5 § fcD S* 5 » m 0 o . S-s 2 S) ss a; F-i O “■g 3 73 §g a CS 03 o ^ll o.SPo St^ g a.a s 3 i? a. s 2i 0 C p - p p 1 = 0-3 •S5-: C M - y^t' >» >» 0“ £ p> 0 a o ^ S o < 145 I Official ENGAGEMENTS AND BATTLES. LXXIX Cs . a a: o - d ^2 a a 3 a> 55 o d he'd § < o p o o CO »o •P U5 1 Ja a p V ^ • d s‘ .tc c p ffic« ® >* M. ®'a'E g-g-ga n Pm' ■ o 26 22 p" p^ ‘ 53 E .55 bi aj ^ r7K . ico o 55 bii 'd p p « 2 0) p a> p > » -d ;d p p .^w 0) a

» ^ u a ^ =3 ® «w 1 ^ 11=1 pj o O ^ (N B S O o 'd ^ fl o S « g 'S o O O o {- o O Ih ‘5*0 S.d ■£« S,'® 4> -3 K g ei .. e^d o bo cS .d.2 sS 'd 5 SS « s O) -d §5 O • S 50 I- V -d g § « .d 5 'd 2^ i 42 ^ ' e d «* gU < _j7 rt J fe§<“ C .3 Tj, f^'g fe 4> ;^s.2 a O Q ta fl . S-gu e d ^ g » O «t 3 g ^ *^3 tS CO «- s o S 3 3*; 6 3 5^ s> O » S “ p = 3 9 3 g r> S P B'S c 9 > X ^ S Cm O o ► « 1 1 2 C .d O) o -g P S — 3 g .3 = = ^90 9 2d O O 'c? t; G .p 1 d'^S 5 ^ d 5:;0 p p §.=•= «s & g u s. «-a o A 9 f. , o"-s = s-3 „ £ « ^ a 5 9 ^ a >,-C C -M M > 9^ « 0 p E — .o O O 41 9^ C t 0 iJ S ca 3 gHHWOO U4 £ . p >» U £ ^-2 £ 2 •s2 T ® p Qg t' c3 d rO l-^g Pp^G s-^l •ii® .Sfe « s"^ & $ r •= aa •am 9 0 Ol d rt ti fM P P w .5 ^ cj 'd ^ P o .l^'o •d i3 ? . 5 p • S 5516 > 5 ■« >a 3 •1 C 9 'a g = g3 C g oS 15 5 6 l< •1 >-1 p* 2 ii K" O •a o ho a 2 0 a> ,0 1 o Cm d ii* 'C Si 2 d Cm P 0 g fcC^ d " si ■§l '■« d p PS g = o H H & p O 'T ‘3 M* 3 p g g" ^ -S bB M § CO .o d « ^ 03 03 p: 3 5 p p p 2'^ S p P d Killed, wounded, and missing-. t Killed and wounded. LXXX CimONOLOGICAL SUMMARY OF REMARKS AKD REFERENCES. Report of Adjutant General of Massachusetts, 1863, page 935. Unofficial. Unofficial. Report of Adjutant General of Kentucky, Vol. II, page 495. Official Report of Major General Rosecrans. Official Reports of Jlajor General Banks, U. S. A., and General Greene, C. S. A. Report of Adju- tant General of Maine, 1803, page 104. See Vickshurer. May 28th. Unofficial. Official. Confederate sources. Official. Casualty List, S. G. 0. Official Report of Major General Meade. Official reports. Union and Confederate. Appendix to Fart 1, Medical and Surgical History of the War, page 140. Casualty List. S. G. 0. In- cludes the cavalry skirmish at Hunterstown. Among tlie casualties in tlie national army were Major General .John F. Reynolds, Brig. Generals Stephen H. Weed, Kosciusko Zooli, and Elon J. Farnsworth, killed; Major Generals I). E. Sick- les and W. S. Hancock, and Brigadier Generals Paul, T. A. Rowley, J. Gibbons, and F. C. Bar- low, wounded. In the Confederate army, Major General I’ender, Brigadier Generals R. B. Gar- nett, W. Barksdale, and Semmes, killed; Major Generals Hood, Trimble, and Ileth, and Brig- adier Generals Kemper, Scales, G. T. Anderson, Hampton, J. M. Jones, Jenkins, Pettigrew, and Posey, wounded. CONFER. LOSS. •Suissij^ 1 760 150 8 : i ° 3 2 •papunoAV s ■ : ^2 14, 500 •IWIUN 8 3,500 UNION LOSS. •Suisstj\[ 8 ! i CO o • s CO •papuuo^W rH 13, 709 •pains i : 2 2,834 1 1 ENGAGEMENTS AND BATTLES. LXXXI f Killed and \v( LXXXII CHKONOLOGICAL SUMMARY OF f3 3 " S' m ^ o tc'» ”'5 i ^ s 2 o c"-- 35 = ® c « ^ n O S^j: ■ e-S^n Ch — t; STS « ^ g” o? ° n" u 2 .2 §^5 ►^S5 go ■go &£>6 o s Ao wO (S . £ g a; [rt i lf js ifl 5 ‘Sc**3 o ■e « 5 J pH g;0 ® «a5 ^ C>S . Ktl ® & c c- bb ^ a si Is o < 2? o -e 15 5 bo &§, K *j3UlSSII\[ •popniiOAV •paU!H •Saissipi •papunOjVV ■pailiM s£ a s g 5 § s ta ‘ C-3 .2 1 11 1 -i ul Of O .2 '2 '530 S O P5 tr . o csO c ^ .2 ^ « s *^o S cl u C) 'd c3 'd ^2 *E 2 pq 2 2 « o s S e-=-^ » S3“2 o o« o 2 £ P< „ fl c «4H 8o ° g u ^ 2 2 Sl-lo O-S § o 'rt O ^ o c'-' 6 t- 15 V »- C OO ^'5* 'd > e d rt 2 , Sa> o . £ "d s 2 0 (;^ "c J a t- < 15 2 o 5>* p 'd 15 c Pm rt £ £ £ 00 bo rt C “GO ° ■ ® cla ^ 2 “ ’ 15 ”3 ^ P ^ 2 ^ go ^^§5£ ^ p p 33 rt 15 15 cSOS s® £Ph •S g Q(i< W tB 1 ^ rt !•-§ O >. U) p; K >» '3 *-s £ £ o £ >> 15 ^ 3 j p: ^ s s ENGAGEMENTS AND BATTLES. LXXXIII 5^5 -3 C 3 t rt H V< Oi O .S . 1 li o Q : s « « o O "S 2 d Q a gw a S gg •S.5 o o 3 S 2 2 's to C 3 C O S a; g a tea .£ o « j fe*j2 S ~ C<^ 6 - OQ o rSi -is sa g'-a § O w e P M & P5 W P5 tao S • 3 £■ ^2 M O o o H 'e pH c> ►*" .20^ 'd ci u w ti3.2 r *n a o ”.&g o te'S ’T’-Se ^ 0) P a o) 30 O o '*-' ti o P bo's o 2 So p o ^ o ^O c5 rh P ^ GJ '-O O T* 2b j! :>. a a c 3 k u U g S5 3 2 O IS o a. a P tt Q >» I ? ^ rt 2 ^O a .^O ^ « ^ s t;3 C p p c<| g I’S” p ^ 3 c3 P o o« g cjC^O p3.o iiT'Pa 'P ^ P uT'^ POP ’C p a « a “ a I _-H § '=•.3 0 P o p c- •-; 5 to ^ Ci a ^ c p -ts .. 5> P o ape? « p I 3 rS p p n ri o p a P 3 -'do r >. 11=^ § «a 3 .w a o ■« c3 4 3 OC I- ; P 'd • p'. 'd o S p-2 a s § ^ o o .2 b'^ a 3 o O S - >3 p H Ph P .£ *0 >. •P c< ■< .2 ^ ^0.2 fa S 2 a a b 3 b o-s i 2 >?§ o «o ^'g a 'd s « p a p p 5 a ^ lo o o 2 — So w fisll Sfill jr o a o c 9 a ^ o ,2 'd ^ O *P ^^d E« p -• a ' . P sig'g’g I « ba-g -rS "n 83 O 2“ 3 a fee «i •O Sh 0) o o ’S p ^ O p o y p .P ^2 r3 P P^ a c> >» Killed, 'wounded, and missing. t Killed and wounded. ^ Wounded and missing. LX XXIV CHRONOLOGICAL SUMMARY OF w a « Q cz: « a a Co «i'rt ^ |> i2 o rt ^.S 1^:! fcJD c c= 2? la G .2 B > a ffi 15 ■si p c? oz v, o.S !'§ ^1 !§ ^ a • UNION LOSS. •Siiissii\[ o I^ Cl •pepuuo^V 14 8 3 80 4 Cl Cl uo 134 2 1 •pailUI CO Cl o n rH CO Cl O Cl CO ENGAGEMENTS AND llATTLES. LXXXV LXXXVI CHRONOLOGICAL SUMMARY OF K § !i I « § fci o o w O S ,2 l§ o d fa. 2 G ©P © ^ CO O a. a o o go « fA O rt •2 ‘^2 ae o fa A- a a c © rt a s o t: 20 0 0 a •- © :o Zfa Q O Ci •c .W _©■ 3 c: w 2 to s rs 5 g«3 •C S a © g g g“ 0 : c3 fa 0 ri3 I §1 .hO C3 S O C3 fa & o Q .£ c c c p c i; © r*'. ■ef rt a; . .W ’^'3 "2 I = 0 w 2 " r-''-S io a a o as u A a 0 © xn O 0 .0 5 s ,0 s 0 o c5s 2 > fc‘0 P*; c3 2 , «2 I > ' .« 0 P O >0 0 .— > o 0 ^ ° q 5 s I S'S‘2 “ ' <3 C3 .jj- ^ ► [T ° o' 5 S' cn •— I O ■ H S © U 5 l-H 1 0 « . 2 0 o e* o O A II >2 rt £h g o' 3 3 o ■" ® g$3 B o >, g s o S B-S 0 rt 1 S §|p i-^l fa rr fa fa « < .r: fa <1 fa 0 : 0 fa •3 fa O fa fa fa <1 a p fa fa fa Ot CL. CO CO ENGAGEMENTS AND BATTLES. Lxxxvn s o-g fe SSI'S 2^ H ^ a i ^ o ' O to ■5>- w 2 w "26 0 ® S a|S2>iSo.tsi2 =^2 0 J2 C t, ■rtOO §■« rt"'a:.= ' a fs o fe '-^ •- o>o A.a c .. S» H cT □ wT ^ p-g to .i: .'^ .'4 t:^ o . a.2 8^ O ’“Si's S’; ■35 ^«s““ 1 5 1 n .to' goO I S § §Ml:: aj ^ '3 o ^§3 i 3 2 L.tba ^ a tT s' •'g §Sq 5 ^ ^ •2 >» SS jq > o c 0 !:: C3 < I's 1 s •g § |o t- c3 ta bO^ P g « § ^ 3 B > b c3 o •c 3 ^ O '^'-5 'd 3 § « ^ 3 oO I’g 3 S B ^ S “2 ?3 g S S S •“ § § s 3 2 <2 ' 2 = in a 1 ^ O *3 _. 3 O ^ 5^ 3^ 3 'a - 3 ^ 3 3.® « Q s i Oi 3 O O fcT C O '3 c? • go o bo^ j O 3 fl ^ H s .-g 2 ^ .qO^B v-t P . O ”gaC5 g rK • 2 (H ■ 3 a ”2 O'? o S-i CJ O 3 3 •f.-as’S g 22s -2 «&§ uj- ^ £* o <5 S'&rS" ^ oO i3"t^ >5 ^ 5 33 >o ° i C -*- t-» . >-• dj 3 a >^o Cl d> O fl ^ ■C &:•« S S gB e 3 go '3 S-“ S'g C' 3 3 S “§ C Tq of 3 0 ) .yg *•* ,3 '3 ® ^-3 s« - 3 ■S5 'bo i 'bo P w E-» a, ? 6 p S ’'5 3 .3 p 5 •B O »3 Ch &. 34 Vj rn Killed, wounded, and missing. t Killed and wounded. LXXXVIII CHRONOLOGICAL SUMMARY OF a rt '3 C5 S O O-i O e3 a o 5^ ■e « o ^ Pi Pi tS c ^0 sIUH Q p S O P to a* , 03 P fcs i 5 cS I « s « S^O c 'P •g "rt S'? § = § cfSB g.'i s > o H3'X « 'P tJ ri -P Krf •a s c3 cl > 9 '> s p E ^ p ft) « a y> o o PJ ^ .2^,0 §.&i^ ■|m"o C 'p o o rt o "H'S ^ I ^-u P Vo 'J> <1> ■g>20 n> P ^ P 2 r s a P « o ^ S ^ O pO P . Wcc i|^ o o c .2 > ^ p *- 2 «- p c ^ o a ^ pa ,p co cc cc o o io « «H o o o o o o o by Qui ENGAGEMENTS AND BATTLES. LXXXIX 12 * xc CHEONOLOGICAL SUMMARY OF <«o O 3 I fl W d I § tD c /2 d' . >»- >>2 dg «2 . o . <£S o ^ ^ d ® d o 0 o o 1 to I o Ch QJ P4 rH 1-3 >» o o fcb ‘£2 P •r- C Pf I P o c '« O’? ^3 .'ta oj '3 ^ 5 o §3 i 'o^l ’“ • © "d-^ sa t a >> c 2 0 /^ 1 " o — tS 5 d .b go © u « O d PJ ’fco o ” o ^ p p CO CJJ 'd S ^ d o V CO O CO ■i’ o'g c-g •l§ ?S d. rS o « § '2 ® o >• O ©o o-g © a w d 'd c< I O b 'd §b j- -'© ^ b5 — o P : in d © o d © gcs <2 o g o O •g« n !>. P l§ •r S - o 0 = CO a (m © -M 5 1^ d -d 8 ^ d Ci . ^'d'2 'C d o 5 d©a 5 -2 ^ d ^ b © d c .2 0^ .d t».'o o 5 ^o aa^ p © *3 g> .8 © P 8 P P 2 a r^'fcC P.b © to ^ d O! •« P t- CO CO 8 . o 'd Ci Cl o o ENGAGEMENTS AND BATTLES. XOI o zi c C3 a s s o o o O < o S ^ § ^ s c3 Lh in “ ° c o| C ■go a fl o IS a §3 ‘C &< 05 o> C cs . go ^02 .S 'S d « •e to O P t,;g M a li ?o S)5S ^ p t-'g o ^ c3*'- >» O M §3 3 ■3 .2 g t-.-a c 23 a jg « eS c3 o a" Hi P P P3 rt (h o c C5 d a o oo °i S o opq P o d C ? 5r ^ .«P S d . '3'a p S t Killed and wounded. XCII CHEOJSrOLOGICAL SUMMARY OF ICth.J llolston Iviver, near Knoxville, Toun EKGAGEMESTS AND BATTLES. XCIIT t Killed and w< XCIV CHEOKOLOGICAL SUMMAEY OF ENGAGEMENTS AND BATTLES. XCV i i iiHi iiiHiiiHi i Hit i ^ I I 1 1 HI i i i n i i i i:i i i nil l "i i i 4 t Killed and XCVI CHEONOLOGICAL SUMMARY OF ENGAGEMENTS AND BATTLES XCVII O A o H? r- c iO o . I .1 'O 0 .2 5 TOO? '5* < t: c m Pi S 42 « g£ i-i oS a p p p p c to II P ' tj o c fco a? o e-i [p ’p s <*-■ .2 p ® p p ■SZ p£ §53 S.® to > C £ ■*'*' 'p •£ jgai a o a a o Ort a ► ■K 6 'nJ 2 ^ o '— (W s ce o .5 O CO t* ^ S ^ rO ^ O 6 ^ 5< o' & H a sl t( ‘^' c ^ rt'^ a '« !S .S-^ o rt o sg- fl • S >i O -S ■§ g ^ « 5 P o e o s p, o o I"; O) o ^1 c >» t: tD o.S ^-p a So 1 c6 c • Jg §02 o .2 S5 P’S .2 rt .■S3 O fcD O s :|& t3 ■« O 4) &■? o w o <3 a> o ^ S'tb . ^ a r^. p p •i-r ^ i 3 3 o 3 & O O ,-r “ *p §5 .sC g)^ •c rS «5 p p O ri Pi *S 42 >>• P 1 o c I S fc s ^ 5 b* ^ c< o . ?:":s g E,2 j: 6 ■SS^d O -p hH £ ^ c >• ■c . « -p CiS P p .S C.2 p: =5 ^ 5 ^.Siiq 2 -'a <1= 2 n-( P 5S " fe:2 C.2 |o'='g i<5 ^ *0 'P 42 i c/ p P3 S'? ? £= >-.-p ^ ^ »-■ j 2 ^ ho ^c5<*h rw Q ® C= a ^ « § a .a.M B ° S .® '§ >>^So c '1' a o ^ ^£'2 •p 5 p M 5 S 02 «« 2o£ ^ o ^ Co P ^ §>■355 ■S ^'-g 2 a ^ ,.. ^ - "o <* Q « " p ? o <*H C '-P 2 'S P *p 'p o c h4 « sa o « £ .2 p S P H >«Si sp £ t^X, o r p CO rt’3 ^"1 a p ^ ffi O p i-s S3® P -P r- .2 Q " ._- C o c ■SwiS m_,-32 aSP< .1 .2 P 45 p J2 Si&;^6 :§33„-3 2 i-s-S cc ^ p 2 ^ .cJ P c 5 = t: a o Ci :g d ""g rt O fsT P^ ^ P .O . p P 'd _d b 5 § & r? "d O C ^ .2 ’1 '§ a d S s o p ; 3 “^P5 CS^3 .2 ■B 3 <1) IS 5 c S .c O 3 S s d > d O ’§ a5 in g ;§4 Ka: 6 Veatch’s Corps, ions of 5tli aD> Foster; o g'Ss ” £ d O £ 00 s 'd CO o l-H fc. ''S .« CO P c« p p Q| P 'o 50 w o P M o 'P P fcH p p C3 "S 2 2 3 e So o St p S •? 'E U p Ch P O O fl p ** 02 a .s p ^ p p a £ -f- *0 £ o' O s I” p ^ pC P C P •- o Jr a >> . W i; & P a to a •c o • £§ £ ■§ 11* o d dO p c « d k s d o B o p -33 42 o •3 a tfa .«• |3 *c to Q Kep c d fac •c Pi o .. p .52 £ CO a § 'o o ja « S o •P "-■3 a P a p p ^ Ci. •< 13 * General Sherman's forces. XCVIII CHRONOLOGICAL SUMMARY OF S'-'S 5ft g-C"' >-.ft ss “S © tT CO O d CO r 3> • O d k • Vl W O pC3 © 2«*-. O go mC b o o Ge; List H O A W W Ph H M Q < OQ < a g'S o 2 4» — O So • Sg'S o o J- c't ?5 S p4 rt o V ‘S’i ^ ^ o "S ti o 2 o (5 o o «n .o ^ 5 C fl o rt *S a ^ O e *o > .a“ o c 3 p o g o < IP -fe o h-; /^S Ol p* 'd © eo CO ^ •s| 'S © 'o jg O O [3 <3 Cm Cfj o<» ■e o ^ Pi S o ^ P4 2 b •J-n «M C3 "S ’2 o » PiO ^ 52 .2 B^l 'mCC ® .3 -e 3 13 'd p,*^ a rt © d S ^3 ?ecjs o .2 t>» m3 c 'u Pi'S • o 2 <-H r- 5 ‘P ■3 B to Pod a © p o K be ^ p .si © d B a o s o © O tT d P d © so s >■* s s © d CO •®UlSSip\[ •papnnOj\^ •P 9 [U 3 oaTSSii\[ •popuno_i\i •p^mji ft « O <3 O 32 ft CO ft O o ft ft 32 O 32 P ^ 5 I & O ' ^ 'd .2 3'P B ° 5 'h SQ 5 ■a o ” I '5 s o S “ I g5 ?'!= P © I’m P3 CO 15 s hi >. ■12 fd pa ■c?; p 5 CO l§ s o <3-^ t o O "d O t'- o ^« T. P O 2 S 2. ft >. ft ft d o © Ih . I “If mil p 503 > p pi^ © p £.2 p >> ©^ ft ©<3 P - pP d © ;> d d Q :ii p £ © p g I IV o o '' k 2 2 a d? d o 5.2 §“» 2 'd ” rt _d ^ o d P 2 "c II - "c 'd O d: ©P3> P o ^ w ^ Pj=^ ftp: d f ..C5 >“. ? p-d © p B 5 B p p •“ © .P t-%'o « © p: Pi d o § P CO ,3 -d © tj p d £ £ ^ d '*-• □ 'd S ■' o P £ 2 © d © S p P PU ‘C'd © ..V -4, !■ d © © £ © p ^ .So 5 © 'd d P £ " S 5 2 LO p s p 5 ft 'S £ © «“ I g M g -W ''I ” 5a £ B§ ■is •- i2 o So .aS c: g Ci o p: ^ ft fee ft 3 ft d o CO . © p HI =i I” p pi d £ I'S . p o O cd 'd*' d S © d ft ft hi ©3 © C o o ft 3 o ft p c .5 CO d O ftft 'p o "© p d 3 d o 1 3 (5 hi 'pl hT hi © © L- ft 3 hi rt 3 o p o d © oO d ^ S ft i> 0 2 <1 ft ..d ill Pi tH .d ,/, ©^ © o = CO Pi .■p © v» ra 3 'C o5:2 •e la 5b ^ S3 C^'C o Mg fi, p gn & *3 5 p ^ Ca kg 3 C 32 C « ^ 3 ”33 .2 S « O >> £o 3 « £ S £« u B o £ 3 £ 3 T pH ^ M 3 SThJ CO r* S 'gt§ OQ -g . o & o U p '■^ rt ^ <% b2 33 CU ei 3 ^ tnr^ A -3 t- a;^co rt ' ab S P*’ 3 w *= 2:: Q 3 ^ c'^t: 3 'tf < ioQ |p ' 2 3 ->3 , = 01^ 3 O c rs . ej '■ O'er t> jh'^ 'O’S 3 -’«2 g &•§ E.£h2 I S §2 o ^ ^ -^cz: w 03 00 • ^ '§'3 3 ^ K! fe . '3 1-5 =' c ®'3 ll 5 fa 3 o T ■go ^ >» o .a % w s a I w i I 3 tX» rt •E 5 P3 O fee o O O .— >3 3 9 P J (N a< o . - 3 ^ rP £ § 30 fa o o p ^ o U'g 5 ® k” Qc p p o fa c 3 P H fa 3 O < be O r H •B B •5* P io ^ •^'2 S! gJ Killed, wounded, and missing. t Killed and wounded. 0 OIIEONOLOGICAT. SUMMARY OF « g.o S g-taS ■3 « “ O o® “■3 dfa 6 2 g ■ Pg . Xfu . - S S c< 1^' a A o c ^ . &= c b .w ^^3 g <: s« ci ■5 o .2 J - P g> rt fc, ft w p >.0 , See *c rt -H © s ^ CM 5 Q ft t, 0 01 © U c3 C C5 5 P i>- ft c^ C3 r— g g « •'1 [3 ’© iS Q © © 2 s ft ft CP CP o V2 CP £-&, Ml o G a- m Ld .2 •-* S ^ in O » . o ■^1 1 o Pi 3^ ^'.2 1 ^ « P* •Saissri\[ •papano A\ •p^m:M •Saissii\[ •papnnoA\ CO CO T^ins a o3 e3 o t>» <; & o O 'CJ § & o CP C 03 O' c O O Pm S 'S 3 cCP i's go g> li |3 O 'a 03 C © •- ,i3 be- ^ c9 .2 a c a P (^§ CO X . *-5 2 P ^ , .B* ^ 11 « o .2P _tp « .2 C CO '15 it -P O • 5 ’:: CP .2 ” p Hi cl'“ >. ■3-= ,3 M (U itS a 3 S. 2 a . 'P -S « w 2 P'S . o 2 p ^ o c jP _CP^>M be •c P p CP CP o © © ^ be rs ^ O oQ 11 < p ^ © ©O 5 Si O TO p. o ’C s« &H 2 P> 3 'S ^ rt P CP ^ >» S c 3 h'S) *t3 O C 4) e3 O 2 M © cs © l;2 &> m B 5 C3 o o-'a Q >0 H S S' o? t-5 ■o H W Cl, < Pm G > ** 5 '3 *0 Pm p X) crj cj a> ENGAGEMENTS AND BATTLES. Cl ® £ Cm o §"'='^3 (S.S ? C< C X a gd '3 £ r3 r® 3 a H sa ££ 2 ^11 P p. p • ftn O JS p . p . p 'p »«l o *o ^ P o 2 h^^.S ^ CJ rt c p, g-n « SgvD a) « S .2 0 o o ao o 1=2 . ft fc, T3 k- 2- " :o ■sa^ ’S 'S rt e« t= o &£■*=! )-M c '' J® S 2 hH ,2 i o'^l u o Es g B 0‘5[)'g) a S CJ © fcj s'^«H §'S <5 2 c3 . 2 C3 4- 11 P ^ ■O fc£) K.S r- TJ Cj fi '3 2 5E 2 O o c c o o tM o r5 o »4 •e s 6 g ^ e § s o - p O 2 c a p p **- 9 g'S p o P t: s <% <1 . o - g.o . 13 of i40[ p rt 80 O p, « V < g-ft a 1 « o -S — oc ® ^ i «2 c a B c W o e3 . » ^ ti» ^ ^ ’S a C 22 O O ^ I-I « . P3 'S s' o >> O >. o r^ ^ a .-O « S.2 j 2 P 5 .2 -M » 8 r-t C O c> « 2 «r €£- a o o O Q ^ S CO § 'w ^ p “ tZ-i^ w f‘g*3 p P ei gS P ‘5 S 5 *3 p ^ - 3 bJS l-l o o '0-3“ C/ t- ^.5 <6 i” P^o ^ 0^3 >»?^o - ^ 3 >.» 1 3 'o 3 y R •P ^ P P o p p o pjO i| £0 » 23 Ci o ^ gr « PL( b'3 'pO *S p P Si s 2 S S ^ o 5 ^ p> ^ p p:'« p a ^ 2 O p p; a •y p p '5 p . g a S o 80 $ 23 p cn 'g ^ ^ P O P ap^ -S 'i pO > p ^ .2 ^' 2 } a p^ a a 9 tl rt P P3 W 2 S -- 2 ;:: CO " lo p 2 TJco 3 3 p *c m >» c o a a §3 •- o ?o Oh & o O 8 « r< ^ p p ^- < P3 c o 8 3 o 8 tt S < p & p o < -P Q < pa p C P « ^ ji A p; Killed, wounded, and missing. t Killed and wounded. CII CHEONOLOGICAL SUMMARY OF CONFED. LOSS. •Suissii\[ 0 ca 11 75* 6 11 3 100 Ci •papunoA\ loot 25 0 rH 12 30 25 C'' 0 "-cr 1, 200 ■paiHH 0 3 18 15 10 15 300 1 UNION LOSS. •Suissij^i • Cl • rH ' i i i 05 CO to 1, 800 •papunoAV 35 20 CO CO C© rH k- rH CO r*! 05 CO 4 7 8 900 ■paU!3 0 • IG 10 5 19 11 rH rH ^ 200 C- -S c,.t: C i'5 a ^ tJ5.5 ■S p6 .5 2 aj 3 c -M* rS 4 J CO i in H i| 2“ 8.S C "B 1^5'® i“i (V I' PS ^ ^ ^ .-i f3 . 2 '=® *5 '3 e - s&H e o o p a 3 -3 0-.-2 o 'B a;- . a r' •gSo; 2 ho P4.9 ^ 'O rt a 'o ^ © 2 o B a o a ■? •*- 2 3 o I p, S ^00 CpH _r c ^ C3 ® n o ^B'l Qj »a 13 a rt .b c:^ o « fa '® ^ P 5< “ Xi 'O 05 «4H 'O C fl 0 ) §P C *« ^ rt a M C 3 GP -j i ;; c 3 !3*s g *3 ** 'E B< ^ O o cy 3^. fa o a ^a a 08 cJ3 dl cc ' ii ; d a) o rt a Cj. “O o Q 8 . o .5 ^ 'p P p, , Cl ,9 PS • "< * J [a 'a ® c *4^ < ^ o 'P 0 3 C *3 3 S O ^ g r .9 C3 O Q 2 p o o > o : a o C 5 [5 <: oS 3 |S> a &» O (S “■ tC=J5- ci <» S to'’ ^ ^ 2 ’a'® o ° S iScOcS ' Tl ' S’g rt CO ^ ^ P = 9.0 S S 3 '^. 3 « S“|Sg 12 . p ^' S^pO iS-SS >.-t P.g^;Eg-^ ^ a .« co ^ p 5 Pp § 3 I g a “ -2 ^ 5 l^PkP O a § OJ o ri Sp ,a S oj 5-2.2 «Sk P •** '5 & “ a © 2 hH frt P o ^ so ^ .^3 a tJ © wT C) 0 %^ 'So a P o • -="2 ‘”02 n c3^ . © 9 P cs f3 ^ © •3 = 0 g« S o-ga S “.sp - *” i- ^ c-n o rt >» ^ §3 E:03 & © . fp .pa ^ .a §ii OT © © J5 P 5^-2 !S “-i. P O P^o c IN 2 ■= ■a'o = q §5 g’2 “S S” ■SSoi = rt ’ ■^§.2^_ *3 c'"^ O «i§i .fa 's . c3 P >» > a H B, a? I — ( § p ‘>3 © r 'i rt - w Hi ftj © o 2 ® "P 5 'S P aa 0 p © o S ^ n Bo 5c J.9 =a^ ' n = “ -■2. <: Sg rt Pi a © C 'P © a 35 §3 O 'S cS P P a t: ==0 «.a a 5 "p 2 © ^ rj< .a 'O ^■-'o I .<.» co o a Mp ^ 'dS ® o .9 >H S o ^ 5 o © “ . ^ gp^ S So GO > . ’•'So ■0 = 0 n q I 295 i? 2 fe . tn sis. s §..0 n .3 = w M iS-aS B H P P ^ P p © _ fa - >• '2 Sb^ i ^ .2 - r: .-a p C.J Sh-I O :<-2 3 1 a cSM ■^g qS a ». . a o " a © © -a a*^ 'S rS ►L © g g %a > © t5 a rB a P © ©e^ o o 4: "a © S © ©P © • .S>-3 «w ^ PO ■» © .P a P : © k rK a O o 5 © ^ © a a-^ B is's^-l^ "^,||ia .1 g n o £■• g •2 ■= >,= a g .£co=s a g fi-'-ngW^ O 5 q A q o a -2. p a . a .9 ► ' p g gqs ;^;!?^ H B 'g O CO .JiS p p k» © e a p >rt hJ o - ^ ::; •“ %« S rfS.S c 3 O c 5 2 « rt ■s fccs 5 / C .t5 5 «’S fe 3 i 3 r ^ n < tv ' O '3 0 ,'’'*"'^ 3 o bJDX 2 tc Cri 3 33 O *3 §2 ^ 4> ^ se g>i 57O too » o O 'tS cC-eO O 3 S £ ‘o s g OQ &■ O a> o o !i 5 ^ a 8 a si 2 -- c 'c QJ . 3 '3 C . So s a . I S-il Sa g ^ .t . *3 tM K tx)« ® nH S 3 O 3 O £5 S tn C.'T « o bOM fe C^.S CO t ■s 1 .’3 § ■5 §.2 S a SBO o . ^ O 3 . 3 05"^ i n Hi bO 3 H It = 2 S ^ £0 c O r3 ® If 1 g.& § O “ CD .^3 ^ Go a 22 2 ■2>< .5. .3 « S o o s g 3 a a " O O O O O •e ?„ P5 ^ to A B CO <1 g to o O 3 ^ fl) 80 “3 ho .5 •C-^ 53 ^ 3<5 li 3 “• So ^ , O o ’o’ 3 j o too 3 3 3 ^ "tS 3 .el ■ o &< O P.M O 0 ) 0 8 8 “ sl O'^M O •= 1 ^ i^o . e § sc 5 a •i » a |»is . 2 >|l| 2 ^io . to ^ o to 2 • 3 S^ g._§ S p KlS 8 o H 3 5? o5 ^ - .3 ^ fcc. 2 ^ ? •hod r G PS 3 2*5 .&s o o H -i' 5^ s' S) 5< Or 53 s: 0 3^ 3*" 3*. '^i-f o c <- ■^35 H*® ^.2 Jr 9 H 5 •- 3 > ^ c S ?| ^ C^“§ . o S § ^'^5'3 II 3 L §1 § b ■^1^1 n 2 8 H -tr 55 C) 5 H o § 3 t< % 75 5 o ‘*^5 ^ 3 CO 3 3 a C3 ?3 b« i^3 5 in ^ CJ -s 3 ' 01 2 p i -'2 ^ S 3 />i 2o 3 rt 2 3 3 a 3 3 ^ HH *> s» « s S3 ^5? 3 O 32 I< o >& 3 O •50 3 ^ O 3 .2 c SP C3 ^2 ^ 2 O 3 S3 O H 2 ® Or. H to Q O ? P n *p 0 — * Cm Ox < <; CU © Killed, wounded, and missing. ^ Balled and wounded. CIV CHEONOLOGICAL SUMMARY OF o O « O ^ i4 S >> . o ■3 a P fco <=co «W O a o « oS 05 F CO V O .2, tH , commanded { c C. 'Z 1 Volunteers; and 1st Indi- ; to a wagon ansas, 2d and d ‘o p •J S ^ B cd .3 OU CJ ;3 S .So o ^ ii U b5 . s o (»> tcy i CA .e'«2 § 2 .u teg I |Sm h " o s*. .B t « i? P cT 5 'd p F § bo M ‘S w - .2 2*5 P 2 p p* Q .P > o' .2 g •o .2 05 « > p bo-r" p •eQo .-,«.2 -B S.SF P . ki d « c£5 - Ci,^ C 2 >% •itS-^ •P.a'g ”§1 . P « bo I b. 2 a ^>5 § O 'F 'P s § go O bo CC*C .a” §•“ P l-S 2a a So 20 ^ o <^co p p ^ a P d •go >» P I ^8 « c ^ p •-■■S I b 'S.S5 .2'i’§ 3 S g 0-2 J ^ 'd d , •d ^C‘2 ^ d «o 2 «3 II p tS d^ 'd tt ^ d PH'S cc<5 g a- W P o’^ S Ph ^ 3 ^ I 2 13 ^ P *0 o o d n P 4 ;? PS -a A PS fB pp O M ^ < <1 <; < c <; <: < ENGAGEMENTS AND BATTLES. CV .3 -p fcX)^ t-i s a ■S .5 ‘y . $2 S - o c a “ " c-^ c ^ u a • 0*2 1 r5 C3 ' — Sm d c , a '■ co.^-- 5^ 9 a K S ^ ^ ^4 :a « S*^ a;= 3 g;S.toa >oj«" a 73 ^ *Q a CO 3 .2 a ^ a gcow a ^ 02 ; &S-d 3 ® C -3 ■• t-4 d a |.i S'? d to O §, d a M I W < ffi . 5 . Co o « e.® 'o ^ ^a d bo d eg 3 § g o a +* ® t* d >» a s ofl c* o'i 5” S :2 - d br^ r|j a ■c^ T— 3 ^ ^ g-2 f !C d.SP M bo o 5 ■“.2 p 2 p .« o'^ c' P d d 5 o <5 to, o> =s o © §•2 P^ p 'd < «M Q o ^ p's 2 P3 a.“2 oj.- j'-p. 0 O4 P ;» 0 04 d P [a *d d o spp g’n 'a 'd a a C3 o 77 *2 ‘d ° ^ 'a 'd 3-p (H o P ^ a r;:^ 5 a ,— d ^ 11'=' 'a *d a 3 © 3-^ s g-p. sao P4 d 56 a aS § a m o o H O o o Pi o o P 0 0 0 0 0 ^'O 73 ^ 3 a c^. ^•3 § .3 §oo <’=5.§ ■• Ci rs 73 ^ e? ^ P p-rt C|_i 111 ° -fl ..aW .J 5 2 o a : ^ '*1 •• o « « - S d 5 cS S ''M5 S g ■ f §aP ■ ^ bSiS ! '3 d ' a ^ a .S d"'” a ^ 3 ^ ^23a ,/ a „ a ■§-ss §■ ^_.,pp|i g ml? -^'5 >> ’“ ■=“^"^=3 ■'i .a' 2 = = =- >& “ ~ §3 5 a?: S S o 0,0^0 0 o g.o52i3i|| CO •a J5 3 d . 5 ^ t-a <1-. O oy S5 P o 3 -S’ jSS ^3- r5 a H c ^ O 33 d 2 g-dp boa a •r «2 g I 1 “ 73 <1 ^ e I o d >H 5 a <*-i a ou II 2.2 ■ga a a ••y Q *o a .SP P.§ tJ) 505 "5§ 'dt' a §-rJ S a ° •a" a ^ p. ^ ^5 ^ Jh 31 £ a'C - 6»5 ■p'S 2 p* .a d Q? •d ^ tH O o O d d 02 c |o ' (N d .5 a fee ’C lb 5 J2 •-■ o »d ^ a ^ a ^ ' L ja ^ C3 d GOja ^ 'd <*H d GO b§ CP i; .aC .s' s p' §"•3 •E-s’S “•gS a a ^ g3b f^6s 5 **“ sSp d .77 dg33 5^.77 a a g'^ G § 2 kd a d hh Lh a e'^.S S tn 3 S P'c3 S 2 ^ u>o 5 o "^1 ts d a gM a |»i 02 G g .'W33 rt 2 ,0 37 3 5 o'^ o d G a 5 a 3 d « 5 cog i . P..a t> bo •c P P 3 3 a a a O P feo s c O P 3 30 ^'d o ^ M a a '3 2P H C*.2 73 ^ k Q d 'S a a . 5.1 < 3 u, 3 a a^ « to 2 o 5 ^33 a 5 14 * Killed, wounded, and missing. t Killed and wounded. CVI CHEONOLOGICAL SUMMARY OF CONFED. LOSS. •Saissipi 3, 400 600* • & . m 70 3, 000 ■popanoA^ 6, 000 200 150 5, 000 ■P^IIDI 2, 000 s 30 1,000 UNION LOSS. •5aissii\[ rf n • X OI I'- X ccTco" o CO 2,577 •papunoA\ 9, 278 12, 185 637 48 CP >.0 c^ c< 150 7, 956 11, 731 ^ •pailiH 3,288 2,309 200 23 48 10 40 2, 146 2,031 S ■^ oc )? 3 cSF 3 >«^ cr ' a ’ r >' 2 ‘ O a - -a « .= £‘1n ^ prt SO IS *5 S"^ ^ O ■*- “ “ a4‘S’-=“ s d s -2^ ' ^ ^ "S .« % C5'tt-^3 , s S *; CO i § • 'S .2d'g^g^lgl?.« .S'S'g'^S’ .^'agco'^ S>3 £ Swo -a'sg „ja “^d'oJg'a'.Mgugoo. o'3®5^“c'S®S“'g § g c K >-S g- ■se^mUCTi I . §"§ pO ® ® ® ijS S §.2 t-coP o--^co S S S . 2 « . ^ . p-l-a (S g pw^'go ^"H-s O a a S ■" ,x = « ■§ “ ® »|J “d “”■« ^a'g y ® S^|2-§0 pa- a p^f® a a- p g P.C — Psui/JCOpaPp Qi o g . § rtP « g . p c ^ p ^ — p^ ^ p s: i- o S 5 r ". Pi P bJD -^ 'a ^ . ^ rtVPrtyTK^^^- rt S ^ 2 ^ ^ p feb *0 P P *S C 3 4 ) P o P goScWKCSiJ'S o 5 0 ^* ^ ^ pi a'«1 i£ g g*^ia2 • 0> C3 o ia §>1 C V O 6 02 .2 w <3 o *5 Q W O < o w '«? pu o o c^ H 55 O 55 P ^ rt « p Gj O W IM S ^ ^ o i-a Is a §0200^ a -aa ” gla = “ p >■ .-t- -o a ^ J5- Jh w ^ rt ^ 2 id p" a” "p §I^a|a “"Spi^^ jh o 2 b o ao^ -o ^ pH«-3 - C . fc« S.-ffg^A, § VH o ^ ?t ° — a o „-^p'g'2 "2 &-^i 1-2, g o e 3 dJ 4 J gOSOOS 02 S » S S ^ fl 2'2 ° C M s* p X b w p 2 § i g ” sai'-a a o O) ^g »-' Yn o .2 'c?.^ ^ Q , S.2‘p3 O ppda ►S £ ' M be O, a> *rs CO o 5 r3 S 0 g g o I CO o O ^ g ^ 4) O O'p* b o ^ ^ v2 ® u2 ' ■ S ^ ► wT*^ Cl, i ^ O g, o r'i »-' ' •'® s,-^ d^ £ >?'s;^ S>.S ^ ® P-J" o i>2*y .b o ^ •2 "T^ 'S. ® to t- ® s'l < p ! ao' ■c »<< ■’•’ 03 .P i aS I a1 I (21 yi .2 0 8 1^ d K'S "§ O '-Cl 3 p 3 rn '^2 O p o cs P g« p <0 ^ s ■SO "p t-, o o b «* & o O ;5 g 5 S 01 o CL a = p i7 P P 4 J o o O^Ob P « .2 |-| b *-5 S 5 «r ;5 *S 5 ^ 0t-5 P > cfi P P O p &:0 c ^ Op" ^ .2 2 '% g o g 2 0.2 ab" s s o< l| , 'b M ": p 't, ' *^5- ^ B O ^ .0.0 2 «■ C? I O <1 P o «o p ^ 41 O 0*5* >H S o 5*'^ o g £0 41 03 ^ O b O ^al 55 CO o ■ . rt .S ■ 5^ -p p ,5 g bjo b P Sow o .3 b pp 3 o Z^s §li »o £ z> .r !ftO CLaC^ ^ p P -d • "^ S • ' '— . g . 2 p ® >-■> I aw-g=§ I ^ a a 0 .5 PO'^ 4) p g 41 'O 'O S5 0 'S- k *G 5 ’C'^ 2 O c o • jj fc- ,3 ^ a^o®” .o 7 ? r-; iC ^ »- 2W^ p a*!" I ^ p4 p a.^l 1.0^ § o o o g ^ ooSOOS CO > b b *3 « 1 j Ph pq K 8 y5 g’S I" as apq a C5 bo s •“ 2= a> > oT s ffi i o O o ;a p'& p> 5 ■ A Sp 3 a G ‘' ENGAGEMENTS AND BATTLES. evil I < M M O MW d d M •! i i i i i i i i >»>»>»>> ^ ^ li* ^**5 I s I s s s s ^ I ^ i I >.'^5 X >% X X s ^ I I II I I I S| ia I S fi fi t Killed and CVIII CHEONOLOGICAL SUMMARY OF o . . ^ O *3 |j C3 =3§ S s| g-g.lo s o . C3 2 p ^c3ao«j^ = p , t. e-g-SS^-^ § cdri CL,(-a>pj P^'OS 'T c:^ o o c'o ;goe^H''^ai4 c 5 . • • . . n3 fe . S.^ pi 5 M -O: &g •t! O JS {V( .2. p. »< C5' 4J - .£ . Ci .53 T' t-.'S pCh "!£ OCi^ >> p O Q of • "'s hi Ci -5 r° a S C 0) t- P : S I i: a •.•s O I? Pi Sl-3^^ gS ia o — o ^ 'j hi p 2 o p h. o O •|S|s •2oP-5 W .J- o -tt £*— ® p oS «i2 Q O TI O 3 SS g ‘o’< « *• ' O o ^ e ®'^ o ^ *3 n £ H « 3-2 „ .2 -§ = « 2 ^ o 5 IP 5 ^ cc ^ P Soc2 ®5 |i I* Is i a p o g. o O *53 $ Q c< e£ l| £< o '3 §1 *■? ® p^ g < 2 ®::/ If* o ^ c ti's o ® P^ P 2 c ; (_ 53 c .0 o B'O S h* .2. o o o fi 2 S L- “ P > >» a I 1 O * P P 3 >- ^ P P o x rE 2 ^ o 3 PC 0) o gOO P c .2» p'-fg "'I''- a'&i gSc Eh K a a « d ^1 c to 'O .S P ; >» P B> . ^ .2 0 0 : h •3 0 s g 0 i « h^ s -So s > 0 »4 •}• .g ^ 5 ENGAGEMENTS AND BATTLES. CIX i £f> 6*^ c=i xn a §§i “ BPS §5 ^ s ^ a H (Li ® a 2 . J a O 5^ . 'o '3 ^ uo -a B a €3 5 ^ S ^ 5 C c o o « c, : 30 So d ^ -d O ft) P ft) a ^H 2 a “ S‘a*^ d d d 6g«i3 o -t • ft) P a 3 'wag 2h E" CO C/2 • )^ .. o Oh^ {5+2 3 o 3 g U5 r 3 3 s ft) ts — ' . a 3 •S ^ ^ Q CC < . ■^<0 O ^ 12 >» 3 w '^—.‘3 g 3 '3 3 fc. g „ Q **-> ^ O g-cc . ■ Kq< 3 '3 3 |gs°3 « t- a o ^ 3 s'® *2 ^3 ft. •C rt PCiH P< >is *"** 5 a rtS s H a ^ *3 Ch o P pH » «< C O / .-. ^02 o .w -a -S'® e3 ^ a p V. a £ B-B 'a a 'a OB" < eu o la S< P O c .a pH-- a ?• rt 5 5=3 a '2 ® o 5 i^l n >* § <: a| g| a« 3 "E O 3 Oj o 2 lii 1 =^ a “^2 s ./■3: o S.L " 0=3 “1‘s §5-4 O'*./ •I tc a^ 2 B S X Cm "" s g 'gOO a t: o .2 c*5» u3 o a ■p .2^ •;? a - ig a Q cc'^O 3 o bi) .'S a.g 03 o bo (U o .2 s i O 'm o p* ^•S CJ .2 5^.1: .aP '3 P s § o o ^ S o 'd •- u o bOPH .» o 5 -a ^ p c .a «.H 2J^ ® rt-d >» a a c ^ a g cc a''*^ OJ . (M I O a, : Ci 3 rH g6«^ ^b«2 O — cL.2.a ^ & a ft) .S. rs cL o .- o c*?i «o bo o iH O bo c 3 > .p ^ I to 11- i 'o ^ . a O O *3 b£ p ’•B bo p 3 rt a 2 Killed, Tvounded, and missing. t Killed and wounded. cx CHKONOLOGICAL SUMMARY OF •— O r- ^ !Tl t-H Sc-ioS- '"a'S on oj ■g .S< o n £ "c t, C ^ ^ t-" o ® ijr ^ ■« 3 “ o lO So; ^ TS 1-, p. » c 5 <3 o ^ n« or.—. c pH <3 <3 K "w cSCCicC rt rt S fl *3 . . O C s o jePQ‘5D.^‘^Pi^o o >4 tJ . e "S-yf p S 6" o o o o 6 d 6 d d CO “S CO CO CO ts 12 >. •g •jf ■g” 3 33 3 3 3 >» >» is e3 P S3 ® O P P s< P Q O 5 * o •SUTSSII\[ •papuuo^ •psnoi •SaTSsn\[ •papuno^V •P^ITTH Q pa O <1 o pa CO pH O O PP h o 5^3 woocrtcjo ^ ^ '^hIh •- -X a) i-« _ CE7 k_ XrtrH‘i'«>S3 ^ o WOQ<^0 c G o H ,3 > C S o "£ c3 V ^ ^*eS’ t- • - rt Ph-Joc*^ s ^H o ' ^ rt o i? Srf -SgSA&ISn X£$Oy 5-&HQr^C.af^ ^rt>S'c?OH o^o-^ — • ^ S 5 fc3^ ■* o fl H o« .'’; 52 Fgo°S gSB-o"^S gS s § fc s 'P O ^ C -» o „ c.'n ;s 'o c <» ® < fr- c 5 5 F =» f “ I . 2 , S^'g, 5=^4 <;iu| o’S- £.-S=g- oSsi gSO ^ «r oOf — O-® ^ S o .— . c rH • • 2 g U S < b S O C tn £ P^ C ” o •£ Sa • Q o feO ” Y« O n3 — o c-j < i-a oQ-^ '2 eg .g fc£)i o ■E^ P « oA ,9 ^ it)"^ ►'S’S p ■ ■ p w-p p o 5 S 3 I O « « ^c« ^5 B- p t-.S «_ija Vs I o uT ® o u U o O'S? c S •r* c3 5l c a « .2 |§ •rOS k.o P.f=.ia rtCO it "bD - fci’S O w »- rS O 'C S.: c &, S O M o *t 2 .2 •Co ‘XO o fc rt o o o >» c >4 S p (H g *g 'p II CL. Lh o O < e- <3 & . t~4 b c3 ^ 1 1 Oo §°g Mg—* O ® 2 2 S o '►-« O ® FT* ^ c £ S<; 1 1 O o c . o o *12 cJ •g s si CO >1 R-S .2 P S;S p.® £3 It P. o > PP s>» S -c g O ,2 s 3= o' .2 K 5 ^ >.S w •& 3 ja & S Fifth I 1,905 |10,570 | 2, 450 i I 1,200 ENGAGEJtlENTS AND BATTLE?. OX I b.odd c "SOg « . 1) ^ ^ c . H 2 r§ c’o^5 § o C C3 O O ^ ® 9 - O) C3 1 C r< •- c IZ ^ P c "q ^ ^ goa SK - fcJD . o to . ^ lO ® r5 c3 *o tiH c a ^ P^ . - . ^ o 5 P ^ c-S Ifp g:oO<:« 'O - es r:: o '2 c'§ PI g C G ^ cil P «XP p 5 tT C ^ rt « »S T - « <2 PC . it'S'Zs S 1 ^ K 7:3 1 tc. c •d ^ pp S s ,12 3 ■ffi-i~ O rt +- t>,'d 73 d 4 :? P o to ■3 2 S 'p ii^ss o siSl SPg“ a a a ^ , S »^o c> CO P to . 2 o . D,^ 2 5 gC«: 'd o "d P* kA - 7 ; t: op d § p * '2 2" Ag<^5 wg O ^ ^ g 73 111^2^1 “ O c o 5 “ S • to O p <3 5 J 0^ s P to c5 &t„-o^'p'd fcD_ a ^ a r ^ S O rt Q ^ P -5 II ^ p^Cidco^ ^ d: c-^ ^ p ci « -d p S 5^1 2 p OOcAdO^O pp-NpaPbiS pp^PpPPp '^'d-’SP'diCP to oTfe £73 © E,.2..£. p 5 ^ c3* p « ^2 SS . CtH ■* P J- « P b 0-3 &&2 i 0.5 o o o ^.i dg ^ rt 2^ © ^ p . d ’■-'< X t- ^ 0 ‘^P c < © ’E 0 . t- 1 - P P S d 0 Vi *5P «*-i ’§©< <«=^C- d X t- d, 0 © "d 0 aa a 0 © to d 0 uj-d P'p tS.^ls «t-l 0 0 P 1 »P b 0 . d >» "d P 0 0 P w§ ;7 d P '-5 g oH ’d d 0 P "o © © d 43 Eh P p P O o -d c-d {h O d ^ 5 tyO K O © to ®.£ £5'o«3MP*OeP*CCH -gSo:;=gS|^.2^ >» 'd ^ p'^ i . SP9 .-■3 „ ■PBS I s : : ■ S 33 S 2 3 S d| d S a s a:! Qp P P 6 £ <3 P -2:'? I ^ « -^ P • O- ^r% P ‘3 S ^ »oS S ssia* i: . o C , 7 , p 1-5 1 "^ O o . o I s °l ?, P. >.3 fc- t- ^ r- ■SA-Soc^ t- n ^ O.9. ‘c? «' S O j^O-5 g &l I h. O d « P 'E © wj? 0 p .2 c 0 P *E P ^ 'p' '"to tM 0 0 Is K, hi 0 p 43 . *p d p © p d 'd d © 0 3 P f. a u « 0 .© P E-'?? c? ^ ^ ^ s '2 P3 d<3 g ^ c 0 £^•73 X ^ X w 0 , 4 : & C.P 0 • © © a s P 'd d P 0 c © d p tK X X 73 Ci d ^ P 73 Ci gppap. p . ) P c t-//2 • - © d j^Hg- > 0 © Es r’ .^-P •r © > to d| o 13. B ^ . «r 2 E d P k d cP c ^ '« P *k O S| 73 ^ C? s d p w]2 c X .2 'cj-'p d g "d '-' fcc^ K P d C d _p ca d >■ P d d a< K < C1-.2 d c & d "© P fcp P p ^ tg P 0 d 0 ^ h> w P 43 ,J c© 0 S 0 0 0 P G p »-5 If © o P w bo W d sa Killed, ivonnded, and missing. t Killed and wounded. cxir CHRONOLOGICAL SUMMARY OF lO . 05 .2 ® bD fci) pO UO •s S to C5 •j2 P. OQ rt "'o 1-1 £•9 K § •s I |i c bo P &> o t^bo o ft &> Hi 'rt 'O CO ^ P H o 702 Q ^ p ^ 2 ^ p 5^ a> «-i -*-. Hi C o II g-o P P I ^2 C3 C io a w < o'- O >> . < CD ■H © O ^ CONFED. LOSS. •Saissii\[ o o o i- CP •popatiO;\i IP t-- 300 1 ■pans CO rH UNION LOSS. •^aissij^ 1, 623 j 280 700 150* ; ! o • © pfi 'd "'d p p p p» ^ a* >' jr blip © P «- ft C 'C o02 Is S C to rt © o 2 ■-50 5 P <3 «,_, U'-ft o (S § 1*. '§' ^ § §. b5-< 1 = "rt ' E: 5 &•■£ ' E (t; ^ Ji; '1 , S ‘O P ^ b s : o o •- S . iSf'PKcc O >> •o n o g Sf 7s F £ S 2 o »< o -aS a fc*^ is ii- o e- . o bo 0:2 ft •c o . s a Jh l3 o .2 tH Is ci &c o ^[5'p i«=i i< a - to ® <1 o © >» 5 t; ‘p = ■« t-H ft 1 p H P, h .s 2 p p © r I m II > !>.g ft P eg © r'l ft U §3' •a “ R i V. 4^ P O 3 1 S 2 S« © > P P^ bo © •Sb .'p > be p 'S o bo (§;a -a” > 1 o'a © .- & ft" o g 1-1 w p*" 1 Sq a © o p P3 Q ft 'p g p p 2 p >» © ft revilliai ginia. '© < V O o H g ^ rt o rt ^ -S >» p Ph rt bo p a 3 5 ts u .- © ■a p ‘m © I-; ft ENGAGEMENTS AND BATTLES. CXIII td-g s'-g' to ^ >-.a a 5 • § 2 § rf 'a S g w 5 o o 5 o o o d 1 O o o CO o a G a tO-;'^ o M*® siz s i bo as pG as ^•g.s *g;P P P> o 'G o o a a a d d a a a • : bo c> a § S a a a a ,G P fcT 2^ 5 C5 •a i cti g fl o •-• a c: C w li is «M 5 c> r*^ a 5 o to _a s 2 ^ t-5 •2*' e-zlJS r“ i g a .a c ♦- o g .o.i'g T O as o a n a a a o 3 g a "a a IJ g G< o G< ,, c & io •arsS 5 ^ fS O io o % o ‘a ,a o o a ,a d d O a &5 H< bo® ap ^ « *a G a o a o a d CO O a a »-5 r=i c3 a < i«=i a a B "I ■s a <«=i a a a S P .2 P -g a bo a a o fS °S 'S'3 . a d 1 S -8.“^ “r g S'a - ts a a w P a a w ® a 1 2 a a a a P 55t> “'S) >• ftx to G P o 5teK „£.a < ai £ o 3 a ‘_a 'S o .s 'a P >» .2 'a o o w " .2 'G •a G^ « a a • - *> ^ d 3“ 'a a [a '3 a "a P 0) a 5 '« 5 2 2 &=«§ c § § & c O W H3 ►, |3 m •4^ Sh O Ch "3 P T a a o f=i o p a 3 a a 'a a .— ' r*^ a > •5 a seP a »a T a a a 'a p— a a a C,G3 ‘3 EC'S a a bo P P a §■3 lA a CP o w < o K CO O CO O M O >5 o A o d £■ O CP 5 2 g.ort<; g S 5s *c? o . o ooS g g g yz j3 S ^ sh t-< W G o C ;;; O --< “5 5 ’t.S’ £ I «= „S.£,g 2 - - n' - l|l§ P I :r 2 S.3 O' . ■= • « oi 5 :9 . g;< o ?r G G CC( 9 r2 3 5 . S'? G w a s ^ c3 c a c ^■ 2 s o L . S . S c 3 g;a <'Sb S'" s .a o , G C >» < • Pii ^ 3 s 2 ’n- g . .§0 <: g< O O E* o 5 « .a .2 §0 •?<-3 *5 - ^ P fcCG cl'SO c 1 ^ a S a a •? S P^ § 2 ^ G S P 2 ■&0 P G 5 S G G rt 5*3 <: « CPJ ^ G •G 4> C tx § > v. •p^ ?>• .2 a fl a P P pG* 'a !& a *& a tS t-> a a a o a ■& a 'a r> o a C a a "a a 3 o O *1 K- 2 P "a *3 P a Q 3 cf £ a CP »4 a a 3 ^0 H 3 a O 3 O a a P o O 'S 0 u Q 1 iP G X5 tc« c 3 a J 2 ? p u; o fcB bD I a rt P « c :P K a S« o a BO ^1 fcD =■ P H 5 G ;a To £ P o j G c ; 15 * * Killed, wounded, and missing. t Killed and wounded. CXIV CHEONOLOGICAL SUMMAEY OF P o 2 ° tJO H "w o a CW "o 'o 3 O Cp- *o 3 o«a &o S 2< 5 " < ^ o c-l Or- c s C c'MCg^ '.5 a » C ■ < b 'o f> 113 8 'a ct '« o O "a 6^* . ® E c| ®w c g.M<03S 9 '=^ o d § O 03 . O 03 • o o g S-' M ‘t ■l“•ag■'g| ^ o ^Ph O yj « " ^ fe gl 2-S c o C3 w 03 * 30 : r ©1 03 pH ,=: a; o b- CO o ■£ C*-=3 c3 -sr irb = ^ fe.C C 73 S iJ'a'? SS S CO p:2 a; n 0/ c< x/ioi c .a ss r:: co d ®4 64 d d-a . a 6-d OQ w ? co S 'tZ' to "a tn* P ^ a 4“ >>o >» o ^a X o3 a *0 a a ^ a a a'^ O oUlSSII\[ •popanoA\ •P 9 in 3 •JuUlSSipi •popuno M •P^IUH 7 ? ® 25 a o o ^ >»v ^ C fco 5 & .2 '^'^1 .y>a a o 5 P5« S •r o «■- ® I® § o 3 2 “-d § >.!d g StjO Z O u <00 P-9 as o to o p o "9 o C) •S ^ H C3 .- § K- s 7=2 >^5 rt . o o 5 rri a i.| 41 .« a o o >%o S Q a C*"© « t>» sg N >-» ■J3 ^ c5 c3 .a ® ^ >» -gg 'i-fl 3 Ig •g>&a pSyd & >rv- O G> lo O '^a s w'lg .>SO S?o P'S o .sac? P 5 C 3 ^ D s' 3-i a 8vb •- o 'O P SrSa m >xn O':? a P ca .2 •« a .:: s Pa 03 ® ”< 2* ^ -2 g&-^ •- O r3 •r y P a a a-< .&'§ c3 S -=3 wT >> ;; p g-a a o o fcH a "0'5 § 1 :^ I ja .9 O •SI o iT ‘m o •po P b ?s o ^ o< c 3 c 3 c3 c3 oo ► p p - o o ‘S P ;si P3 - a n ! fc 5 8 30 S « o o o' E ® /i^ §?-5g3 I o3 ■s ? « a s< a I a>d o P ?y — , j bJD « <-5p •i” »*5 -a 5 a a -I ^ w° ^ rt dS <=•3 oo. Is §3 o .-. O 2 , „. ss&i' •p o g 42 «?4| p-gi' °ScO: ^ w »- o ' ^ p- o 5 ' ■§ o «'^ J Of p p b a 7 ^ a P ? 2 2 ^ fc ^ « A-J ® o aa J p g o ' ® c5 rS 03 a I -d-.S ? c.-^- ' a ^ ^ t-, ^ -f^. ^ O • « ' Q ^ i* m" £• g -a g g- O “ ,d o O O s 5 g ; ^ 5 I S.O ; PJ p 2 e fc* ;! §.§> I g.^ o t i3 g3HS 03 CO . 2 a wT O o > a 2 5 «r O O J^vra £> ba 5P a o a p3 ^1 o< a o o >.ra t- C*a a S «•£ r?> H £P .S’ to iS IH » bo 2'a S a a a ENGAGEMENTS AND BATTLES CXV C . ci‘ 1Z s X 5 . 3 H §) . tf « « • rS S.2 c n J5 w.Ss ^ Ire.s &oOf> < s s o o fl ^ Oi Ch 11 C3 .2 cs Oy o to K.S S 2 S S s:« ’! a> c . toc : « o .. y w > O P a :§o C3 >» cj « **< 5 ?3 nob |1«- y o'l ^ 2'';! GM.o • rt QJ ^ ^ &=13 oil ^ S C f C ^ . «2q C « >=:o ^ g CJ 1 o s 2 < e*-. • CJ ^ c 5 S X « c3 rS 2 X a to •c P 5 Hi ^ 13 ' a ^ »r ® 2 4i t-, C3 o ^ 'a ® . C3 ott w O^ ^ rt o jh 2 o O 4> tH 'rt'® H «o| &'C o o pqo oY • 5'3 . m KS> .U *-< CO rt*^ t, ..'O •- a Q o cj ^ O) h'*® .^C5 o o Ofc- H I'gQ rt -g ia C'-' - 1?® •§ a o O L^ '3 2 e.|^ ^1 o 2 ^ a X a O g a - .2 % .2 bo .j;o2 0-3 ® QJ C fl ® SO Killed, wounded, and missing. t Killed and wounded. CXVI CHRONOLOGICAL SUMMARY OF *'3o 'I'Sd 1^ & 'S .52 P ^ r ^ a ‘p pS ° § fe'o p 0 £ JS < b 0 p p rt 0 3 0 ® 6S p 0 "o 0 bo3 p fp n c Tji c (LC ♦- 00 a *-■ o I Sec C Sio ^.S .3 a 0 o e " u • cj 01 & *S JS '§.2 s a *0 c P. p 3 'o' < P ^ 'd 00 P SJ .52 ««-i l-l ° in • <-5 TO .52 p P42 00 rH rM p TO 'd '~‘ 0 p ■•^ PP3 « a 0 0

2 p*^ 0 W 0 P 0 d w >» c 3 bb sa^ C|a ow^ o 5 S ^ o Si fi tfO s V fcX) C3 . bi'^ c O 6 aj Ci n . ba p c ■ Jt: o o « h J Jo b£ >» P p || ;-■ 0 Ch V p'& p 0 c «... 0 p be K a « 3 'd a 3 IS •e p 0 be ‘5 a c 3 w rp 3 a Cm 0 << 0 H CONFED. LOSS. •SuissiM 0 0 0 ■* • * ^0 ■ 40 * 0 . Ci • 0 • • C^J ■ a • •pOpUUOA\ 400 009 8 0 0 ■pains 0 • rH ; 0 100 LO rH UNION LOSS. •SaTSSTi\[ 200 065 '[ •' 0 • . CO 1 •popanoAV 0 20 4 579 30 0 ' CO C2 rH CO I 4.0 •paras 0 TO 0 0 n a • CO LO CJ 0 ; TO rH g §■ • a ■g P O) cC c OD . . '^§•5=? Oo . ill O O 1^1 . 2 - ' * S 3*0 O s « |b S c o ^ (2« rt c3 S« o C a 'S « r/T O ^5 ^ I ip ;p.cW P « 15 ^ to o pi] Ui ^ O c3 •s« 0.3 'c => 2 S '*" '£4 a «§ to a ^ H *9 ^.Sr .2 '0 s .2 a S 0 « p .Bri C3 c< •I4 ^*o< E-i S p: a a KH cj a ^ < TO 1=1 TO a.a.=3 a 5=.M ef o ►! C « .2 O 0> •tS P p p w M o ;h ^H<5 o rt % ^ 2 « "w p is p ':3 P P o p c § c; J- hh S o»o I s.§ .2^0 511 9 o »rt O O c5 « . O P •« o C P s P 3 POJ ^ o . cr N « 0-.5 *.o o 0 ^ ij C 4 tig S np P< o (-■ o ^ • c - o to 01 O.C r- fctO '9 IS's i g” a ^■ 3 .S>g » «p3 io^s S -'5“ .C O P *-5 P fcs « . r»^ ^ P <-^ w 2 c< o § P tM o OOP 5 O Co-;; p O 2 'p •s"! t .ado > s s 50 - 5 > ^ « .3 g I.' ’'3'''’ s g.S & C3 g o tS P o k« <: "p p o O b a> a a rt b P rt cOtS O » 5 o 3 Q 'o >» 3 ENGAGEMENTS AND BATTLES. CXVII K tjD^ 5 >» s {>» g to n ^ t£-K ^'p dl Ss '§'=1 ?» o a O & . o o^a dS I cc-< ^ to %• >3 " c> s 53 5 'd p « O b fl 5 S g g ^ ■ ^^35 C 02 V] . 02 I O «M &b” <£§ 'd i o S a . .2 .;£ oj M “ ^ S ’"§ >-5 . r !5 o . a . dS d| p a •|“«-L -- H-s p bcrs o' -ba^ §■“ C di-^ S « p P 53 O . *o a rj G p P j p 3 a> OD -d « o S . Ftf( C ^ H ‘tc g ::S6a^ e§«5g| § g.»’g ® O ^3 a o g'Sb'o'a •°s p §.,p i5 '-i' a a o £« §-S5 "S o P< <« *3 © 1^ o . 2 - - • - s- '^ « 7.2 > CD S 3 •— ( Ci r^ &.a “r p aJ c - § p fc5— S 'S &. P s a s i3 “p p s -pt: P o *“5 ft a 2 P3 ;s cj pM sg 2 o ^ 1 go d“ § il§ C ^ P 2 S b P3 o g CO s|l is “- '2 P.I s a'^' 'c?« 2 wOtS ?!§ 1|.2lj &a Of? K 8)35" ^ o .2j o O H b " 8fi i- _ Og a § o o go O .b k-; w to •c « rS-fa'g «rc •C § 6^3-^ g bcH « w a d, , CwJ '“Ooo- - o 'P P -•^•?a S'& P P gQ o P a> c P •- p kp 2 .ZS^^-Z a PO^ p O Q S ^ rt >.p c.'o- O ^ £ .2, S<>3 0.0,-' 3-^ b . (h / r ^ ^ ft b © © 2«._ ft gooo O-S Ills': o bte -P « .® © P &i2 P3 -- p o 2 L2 ?5 ©O S S - o « g ^ P p" .2 P «*H u p p p o o p 5 < .-r o ^ ft p p 's 2 .a* o a> a .2 ^h'b W ©TJ 5 •5 jo <3 ,2 S<=‘ I s '^- u-S O uT P .52 Sm |g«S<«0 a O 2 S o I P O © §2 o *iir^ ^ di © © u2 © a .P 3 O o cc w G) a £ ■■C < >, g o 'd >» a .to w a "a li © o CO ^ O boJ © o < S3 p . © o © 'd S p © top .a Kic. '2J © p O P © o 'd o P Jh .1^ ; g 'd : a s < <.a to 3 o; 'o P3 1 3a os 0.0 o a b £ P £ a SO £ >> S£ a Ci d . © p^ © 5 'd GO P .a"'© SCH ^^3 .2 ■*> io P4 p: p 1 •r a .§ I P.5 © to .^O p © 20 - p" o .©2 p p , .5 a I I .1 ^ © g) B ^ o o - © ^ p O ■?2 © ^ pa 2 p“ ^ © t: 9^ 's a .b° Q o ^ p^-d as rtpq y « o a| go o to 3 :! ^ I* t-. 9 >> ^ 9 9 »-s Killed, wounded, and missing. t Killed and wounded. CXVIII CHEONOLOGICAL SUMMARY OF m < W o w JS o o e3 c:5 c o o ^ ^ £? • ii“ a > ’ 5 d « K" ^ ^ 2^ B § si ^s 5 CJ 5 - eg . K oiS ■ i.bi o g 0 0 0 0 CO »H -2 g CO g 0 Ci ■sSg 0 hi bo g 5 0 c< d CO S Ci >> 5.^1 2 , d "£ « i d" d g g* d g 0 g X* g" -iiS'gv. ©j? 0 g g CO 0 s •“5 2 © &® o g © 2 d © 0 d P « 1 a © fco+j d CD d ^ osses in Casualt Medical 299 . 0 -fc-§:a Ini ».^o c 9 S © CO © © c^g. C p 4 d © fcD *5 |g d © 9 C a © bO*i d 00 g* 'd © © d 0 • © © d 55 C =3 p 0 P p CO 0 CONFED. LOSS. •J9uissii\[ 000 ‘I 0 0 Cl •p9pnno_^ 0 Ci 0 0 0 co” 0 0 0 1— 1 ■pait’N a Cl Ip cd 0 0 CO UNION LOSS. •Saissrj^i Cl i-O rH 0 1, 910 •popunOjW^ 17 279 0 COO 1,679 rH rH •poniH 12 55 0 0 1 — ( Ci Cl ^ 'w vL © * ^ ^-5 4 _ '*^ r^ O fcO >«» 2 o © s <^Z5< rt o a © • WrS'O •rS rt ci ©•■ rt 6 .P 5 !)*^ acQ ^^ C ® ^ ^ «S'’gSd -f-!; E © ^ j § S jo g a © cs'd ► o C3 ^ B a ,d 8 s cj rt > >2 ; C^'o i bC^ £ 2t '^ pa , ij 'B .1 M p « . 5 P “o O I Ego SOo rs 'J? ■ti « t- P 53 © © -. 2 ; S W O »- d .d ^ rt S © © © a c CO g O ©'^ ^4 bo © uT d bSi o c ^ O a^.Ll d . o.d fc g *d‘^ C = < fc O 'd ri © S C r 3 © Th o ^ dO .2 © 52 '^ I ' p 4 S ll-K ^ o (d -2 CC »*=4 gsil O-p . .®S I E^i « d © , -•- ,d .S S ^ g Q £-^ ©.2 ’d'«' ^ © § O © StH © d ii Cm d C © ^ ® t: sso H >,ia 6 § <% © S g§ < 3 ^ «M *1 ©g "1 "1 p i ^0 'd d d b> 0 d 0 1(S p P I s o c S s © C § d a © ^ d '^’.B ©'& ©i> ci.:;: H P ii o lU) .3 J> ^ d *-i >> 3 >» g ^72 g CJ o page ENGAGEMENTS AND BATTLES, CXIX oO ,c3 ^ 1^.9 o » ^ rS 9^ 3 , I^* 3 o -5 i02 . 00 0 p 3 K § 2 e £2 'S e •5 £ 3 3 0 Sp 0 0 [4 c LO 00 c< CO cf r "o ^ ^ t: fco g ® 5 c 3 3 'tJ o o d5 00 >» « 2 ^ o o ^3 c g p >> 3^ c ^ r/ p ^ ^O ^ 2 3< c^ O --2 ^3 3 CO •9 3 o a ^■r3 fCj 3 ■?'S S to O 0 0 *3* ^6 ^6 Cm 06 f-t ' 0 P^ .. S;3 5a . 2 ^ .3 ^ £ 3 0 0 (N Ci a> <0 ® 02 O 3 i>.*^ 2 2 S ^ •< ' c-1 3 g" ® •B > 3 g 3 ® b-x o ® ( £*m- 3 3-SO 111 ?* t- <> ® rT § t: o l^-'S Q k s a o 3 o ® >> 1 1 .SP» o « /<: Q Q 3 t: 3 ® 2q S g" o bP H 3.3 •S-9 O ^0 •c 02.2 u *3 2 ip P P P iO bj) bo be .. £ £ o £ o — O LO bo bo bo bo -5 -5 4 < bo -5 bo iP -5 bo S <: bo 3 < t Killed and wounded. cxx CHEONOLOGICAL SUMMAEY OF CONFED. LOSS. •Suissij\[ OOT 0 c n 2, 000 •p9panoA\ CP 1,000 0 10 1 2, 000 •panni Cl 0 CO UNION LOSS. ■Saissiit 200 1,400 ' Cl ‘ 0 250 3, 176 to a •papuno_^\\ 10 18 1, 755 0 n 58 30 0 lO 1,155 CO 25 1 •pans 0 4 3 400 4 13 16 212 0 CO 2 ^ O s '3 O c p .t: B ES c a o fcfl fcjD c c K CN CO t^ Gi 'o p Q t'* S ^ 05 i-i fccr? I"" ■'Ss fco tT *■ M >- c i:jD o b a: o~ - 3 s i o d ^ ,p Tii p +- p Ot^ C3 &) Q Y-' 'jj a fcD Q r^ (- tT P ^ p fS o 'O o> st^ a p 43 5 I ®aB [: gCl§S ch o p a s ft . w fee o to tS ^ ?r c 3 k. ,.*• p-^'i* cT 5'Po< cf ci g d ‘^K i|B d a > fcT p 6 CO “■|go g 6 00 2 2'B 0 .a fc- 1 2B t> P p 5 .2 1o'=5 'rt P a b 13 is 3 g -P ^ «.2.^s.d 15 b "Is a .»- a {y .2 0 '.3 io p c: ilS-3§ p 0 2 0 0 vi.; CJ - 0 O P ••-> o »2';3 2^ 'd o p a> s K ■pS a g . W 2 r 3 B s , a tc ^ b • » S.2 P 'o >» ^ ft .2 ^ fp O p _ tD 5 c o 3 u >-• p 3 fcJD >» a ■< t=^ S uT rip c o P I- -al p a rt ; H p II UjS WJ ^ ti'l •- s 52 O a < c w •i& •r o .!:c; ^5 5 'p g g p o ft g bp 3 o so o p '§ 2 tea ’C o W " ^:s p ^ CO Ch I" a5 s^« ». ^ O ^ w cj 0 ^ !s-S 01 a s y p . 5 b 4-1 o 3 t%t: < O IS ? = ^ 05; S’ > > B ba P 'P f;s> \4 to W O O a •S 5 J» rt ll a ® O .2 M c< ■S a a^iTg. o £ .ri j- ^ 2 .^.3 rt ^ ^ ,ia o = a'® '« fl '3 c ^ l 5 ^rol &>! ifl?2 si a c C e. 'm -e &o la O Ch o « ?a o o & Ph S . p p ty Is 0) c «l >.3 g2 a ai 3 “.S §OP o CJg'S ”■&! p a 2 CO P ^■«s ^ 2 rt ” ‘"i saS S.20 2 <5 .1“ £■ > ^ > & p — -^kQ 30 . c=3 b03 «sS a ^ ^ «M c3 P'S •i ^ 2 o ^s‘5 - cjT'P P ^ p 00 S| §§ '3 § '^ 5 o^ :P ‘^'5 oO ^ .iT =* p«,9 00 ca ® «3 S*s £g "2^2 fe S'^ r-t !C .2 <0 CO « ^ Q ::1p” .2 «*■ a) P 0 o '-ft P^ •=5^-2 3 V 'p p ^ « o « BS 9 P Ci o 'P .2 ^P3 ^ cl 5 3 •ga PCO p'^-s §1 ■»5 CT' P t-t i d> .5 p O 5‘rt ^3.0 &*Q O ^ <0 ^5 § T! .2 o p -2 O .- 0 CO o o J3 - J ”0 O P p 2 .2 a >» r-i P Is P P P l< P - ^•r i a d) cT p 3 feo r.P? -P to-g <7< C/ O CO Ci Ct < 7 t 71 fci) bi) bi) fcii a o Gi Ct Cl bfj 2 * Killed, wounded, and missing. t Killed and wounded. CXXII CHEONOLOGICAL SUMMARY OF £0 *Eib'S SI-1 m 'S ^ c S R 3 • C3 •pS )->r o ^ fcD R P« ^ C o rt U'*-« Ch 3 <: a ■^6 OJ ^ p? C3 0) a i= ^ C'^s: |PS Kci^. «5;C0 O hip pH Si 15 a o 15 ^ ^ *C s 5£0^ O ^ci ^ o R O o a> a fcD o R C fc,Ci 0) ^ « c eo o s? c> a a 0/ C5 R o S “ ^ o |2 S i_r fcx)Si '3 _ R s; c t: PiCO<; P-l r"^ ^ ^1= 2 o *2 g.= gs£ t <> o 1 ^ a ^ «.2. ^3 offiAgf ^■3»B rV 5 « .Si O H O O So go go ^ . ^ci "C R a p< O R « b.o s. o CO o tsco S3 a '3 r3 R "e •B S fcps, R a 'o o =g r aO . g o a >-■ =3^ g g. ■So g M ^ ^ O L»r o R Sc«! o a P-H I p- • I oS> K -S 1^§ Is I" S S“ &oC) Z 2 Hfl a pH R 5P? OK CO ^j- a o w OCl Ci< 3.^2 |‘§.| p "r SB ^ O o CONFED. LOSS. •°aissix\[ * o o * * o o o © C •3 C* I 2 K >» c © 'S s •? s fi-S CO © &£ 3 5 o< so H «._, ^ o a - •a ® § e S < o b s'd'ijfo o*a*^; ?§r.5-:ss.l^ a S &£ o a OO t: o o >. ^ s _ (- a< •I I iSs: CO tn' 3 g ^ Ss^gS ^ S“ bf S ■'3 S^.p- vn u . au '5 a 1 fcX) 5 I ‘-H •P . - ' o « <5 .1. &, .:: © © M f— '3 Q a . © '^ iH .w «l § 2 ||^C ji^SsS 0«|lsfSc3 '3’^ g gii^o'S goCOr S 0-3 I- ♦-pH «S s li? © ( l5£‘i o R R R O , ^ »H tM *,P j o © © © .52 7-*pp a e: , R © © © .p isoocQ jag cjM "3 53: Ci .2 S .frt © © a a © »£ © w -O © a: 5°^ b a .a © 'O Ph 3 'S tH R © 3'3'g -c-i g R S & s O C ■a s ^ R o £ S ® 2 © p (>>© g«gg a R a U5 © o P=1 E a o .6 i._- o ^ ^ P> ©"^ © K C Hh l-H 31h.& © a a © ^ a a R © a K "r (h 55 © K 15 i S3^S °s siH;: S t, R O '!'§ lo o g g a g Z'6 a a ■3'gS’bl .is jS^ R S3 © 3 © 8 S^-aS"? © ^ '•^ a R S H 15 R a a © a 13 > R a o 'S © , • is i-3.q5^ O H > O CO 0 '>» © 1 o 52 © R ©P^ a R ^ S’ •g « O ^ s . R 6 g sa O |5 R a fcJD a- R a-^ o © > R fc0 2 &£ fejD a a ; <: c fco C53 CC C5 bJD? C^ © CO ■^6 S3 ^ © O TD^ ENGAGEMENTS AND BATTLES. CXXIII S c-SfaS £--3 ^ A. tiM 1“ . 1-^ C MM Gi K 3 a o d-| O.S .cc CO . >» c 3 «M ^ O’ a a 3 « SO Q O C ►*5 c ^ o cj Eh . t3 «M 1 ©'3^P S« ■ ■ . .C 3 55 M --■as 3”= S iS io tc .S ..3 ^ - s.^ O CO ■■ « c . O . *^o C f£- ■e.2 CO EO O a . 0^ O t « « ft ^ t-' o S ft«*H ftO <3 h 3 ^ M A^ - tn 1 ® 0^ S oO'gK ca ^ S'? S o' O'-'S^oSrt^c'^c ^rt®--j*SC 3 g) ♦ 1 >S '=3 tB-r'C^Ss'c §< 2 (§ = ^-g=g.§g|«igS- S“(S- 5 '^ 5 ||‘ 5 ’§ rr'MM O r-c.s-^ „ jE'" S.H"^. 2 .a si «^'' I go^ldS n SCi 4 o °K- c.^ I g'^S ;S lei; « “e ® £;g op: C^.S^ g ^ 2:2 3 S c «»M .a «< ^ § ^ ■ O ft Ui c .RO b .2 , '2 (U P. ^ «y .2 <0 ii bi)'^ !5 ^ ®i 2 w B O -a 3 .2 a§ 'B i !!-iS sa a-” (m bD «< be O/ O Si 50 «M a o o P's O Q ^ c> O” A- « Q § ’cb ft) oS s a- O C 3 /2‘3 '-’& o5 (f o ^ c « B cT I > G HM ^ ^ a) >, •.$ i: — - s rh -r O^B >.H Q •3 O g*S g O! .B a g o - 2 , [>> '3 .g B B ^ S 5 *r 5^0 c 3 o '-'a) e-s '^•5 -’P d 6-3 •B S o c o«:| S -“ £ ai p CO 4 J o ® ^ §j^5^ ®.saS a 2 “ 3 ” •§■-'’3 ..'5^0.3 3 rt --^ . c ’■-^ ^.•^1-3 = 1 i II :!!;o I C5 O o MM ^ c 3 be beb S S O p W S W "Zlo c •? ® CO to » £• O s o G 3 ,a a s c p c* O * Killed, -(vounded, aud missing. t Killed and -tvounded. CXXIV CHEONOLOGICAL SUMMAEY OF ENGAGEMENTS AND BATTLES. cxxv K K P3 P3 K ^ g-g ^2 o I S oCS pH '-a _g.|) IS o c ri o2 U ^ .X. ® c?r9 o >, I- C.C to £ G O -c L-S ■*; 'S G o ^ E; rt « n g* o r- -T leii tO^.'G C 3 . "T" ^ ^ t: p-x ^ ^ c 2 tT . '2 be , . ^ G D G 'T 'G =;s::sg^.§ K o 2^.<3 g 5 S c - G £=„ g I ^ a & III? If ^ S -S; C .'S 3 a 6 a 3 §■§ '“’lo " io-S .f5||| go ^ '^3 £ w te ■“ «'0^ « ^ '5 ^ cs S "C 2 P 3 c5 53 I— ■ c -*- P «.20<:fe'50 u t: S ^o: K G ^ ’rg 5 2 p 4* *3 «•-< ^ S o cc’fcb'C b ^ G ft w CC o 3 "k ^ o t: o ft < . I-; >» tog •nrs €3 ft p 3 « c.^ '3 D b c*^ .2.0 w g'bJ »s ft o >» o o r fc£.2 ft--K ftjrt ^ K g g ^ p.2 P : o i ?E < jE-g, ^ 8x o s o >. P >3 &4 P ^ p ‘li C O >1 - H ^ 'S o o c: ^ p o oi'S-g CO &g2 o c p "o| ll'S O; 73 »- rt 2. wm'^. I" O s p p p gc<; *5’'^ a> ta- p ^ o o so I. C N ■ gSWE H 'b c/ W'l ts. O o B g h-3 P P M H p S iS OP o p .2 :P Q 'b P k a £ Ot Ci k> I < P p »rt a ^ Ph p a o .■b u k» s a i«=i^ E* ♦• •i & p o ..c^ p §3=2 .&>5'^ •l 3 '— . 2 * > OO^ 5 'b 'd pb o c S g 5 =^23= 33 0- o . 2 g •-^ 5* <-^0 r- ^ pa t: - X p - p p - 5 «2 ^ ^ o a k» pa I ^ IS ^ o -.b pa pa u & ;g C a> a> p u a o P o i-< ^- . pP.2 H o '5 p b« p . P p S .5 rb to V} 'P X bo o .2 ^’So o ^ p o p p 1^ fc4 P O 'C o d p p o o 2 M o bo ^5 o . o go ■S «r ,2 P P I ps Gt Gi C^ C^ tfj rj^ ^ VI bO .^2 c> 5 O O P' 5 . o Killed, wounded, and missing. t Killed and wounded. cxxvi CHEONOLOGICAL SUMMAEY OF < . O Cl — rt O G §5 w c - . § 0 % p gs" haw o rt %0 F= hJ O ^ a t, rt fee r_r |=;.| ^U'yj rt ^ a ‘-two ^ £ o -CO »4 c rS ■ a P r3 4) o go g Is n’t °»l§ ■E — S I a - g § fc Pi a - ,— V 'C • 5 g=g "'-' ^^' -O ^ ^ G; 2 I S GJ i gOi Oh- .ao Cl 0 ) i-( fcD ^ a ■tj h (2 U h G) ®o o 6 02 ^ vr M 0 ) - - ^ h ^ ^'2< ^ C^ 5 ^ o « g ..“ •3“^ a s o i? & -T «-( a o _d ■- - o « n w C o ~ Gl O O Cl H V « aC* S I' >> •r S .- o « o ^fcc^o pf rt S E§ Sf, P O GJ - I OiSi a P & S ^ o^i § aO h qCC ^''d *1 o o T? r> . C!! o a .. o lO .2^ B B G) a gag .2 Sp <•1 a -3 il’o ' 0 E? f 0>| sbi a ca ^ .= C h a a ^PSrS O -d «§§ ■- - £ S ^S f«i ^ o :s<; H H o ; : « S : V 5 o 5 .0 a k O G> i1 Is Q b a a a P'd 3 w o .2 •c^ pH a . 5 0 bo pp.i: £ _o T- a gs > . S 3 0 0 h 1 a*' "a > C - fe: ® c ^'g a tjs a h . 2 ? h 0 0 !-• s cT S a a a a d a 0 'a a a ®-3 to d 0 a % 0 - c -d p a P e 0 '? H 'o P 0 Q E: a h "55 j^p 0 P 0 0 gK 'e 0 s a p 0 0 d 0 a tr 0 ;z: Q K H 0 « cc P P a O S .i.r c g >» o C 6 O a 02 ^ O O o o ENGAGEMENTS AND BATTLES. CXXVII 5“ 'C p P s •si o o ^ « O eo o C L'^'O o ’E ^ ■3.“S c; o llo' *«■«? ■sll 5 o a S O.W o 3 g.o c-ds g = -5 -h- g C 5 “ I t: C I •iiO r!=i -c^o.CQ C'-H .^o OpH-.C(rt tn fcf ^ -'2 S ^ 0 ; 'y,.^ c u.' •• c5 K- a ^ J o 'E -.-p a p S y.' s . £ p -3 2 g o ^ ^ -^•< o - 5 « S « t. : «.2 O O C O Q' ► t - i-, ^ c'^ JS E c "S •- 0 ) E tj 13 flj -r c ^ S S S o ^ e'^ r c C3 ^ ^ ^ Ortd § bS 9 bI!.aP “■?- g. 1^2 .►£ O p. < « K K « •H-i£°s. 2 g-B|§s:: •5g.^;i-rtoc»oCc3: g fco< C 3 SO

» .*©« Gr^o^> ^ T rt ^ wi P c ® O « 53-0 pen ^-_ i^l § « o o ^ n o . o ^2 g-S » gses'g •g-- 3 £ o -2 ^ .Q '“T C. 1 i;S. .O § g g''^ G c d ^ ‘“'S e2 , 1 2 •9 I g .3 1; bo n r ? cj o n e c ^ jg o, tc tr^ c O o O 3'^ s-l £' = <« « >.= - S ■. Pf "i 1 ilo" 932 p'-'O — •a-. 2 «n *2 S III § o p 'n ^ I ill rt §<- rt O &.i O uj o’j: ^ es £ p C3 O C P c'^ 3 e e n C3 I ^ o ci « 5 ^ p P'S § . £ g > be 23 |5 O IT ^ NiH ^ fl 5 £ • o O cCC;3 > « .0 |il| - § 3 § © c3 H g f § S £ ^ I © •- ea S g« Pr5 'tf 3 gtt rH 45 c a . 2 S' .2 8 § g n & rt ^ ^ o H P ? 3 .0 o Si:^^ ^ rP C cc 2 5 Orrt ^ «*-• S ^ . ago ^..s 2 Illl^l-S Q n 'P ' ^ 2 "'='' ba 4< G frt 'a o o H S B-- O.'O-SrJ ga , a o c n ^ jh n ir: O ; a © cf - 0.2 &*a o > o *i O.i : 2 ='|ab- -t, j; d! C 3 m p,,| 0 b a'.a>d c 3 ..j 3 W P'Ci S 5*0 rt I S .£ is 2 2 5 " ap g" n o**^ ” 3 a ' ||o§55| §1 © 'P o s‘ = S g <: a 3 :-;2 2 o it:%o n . o L tn n b o ^ S £•*- 3 o a a .g g a-S _ W C3 d a 'O s « p £ 3 L® •§ J ^ O ;a To O P P O cf O K OQ W 3 <» Ji: C Js r CEP £ o .d O O 00000 000 t Killed and wounded. CXXVIII CHEOXOLOGICAL SUMMAEY OF O 'd “3 k 0 O ^ c3 w Ph o g § 2 -S S S o g » e S Kg g •g ^ « rH ^ rt O ^ "3 go ’a o o o ^£:5| •1'“ a ^ a o ia f=< 0 Ph c ° ■cl's « g.o -i:'^ Ph ^ (m ^ « w « C£ O - S n tyD.2 fcO 53 P- s-i ^ p n a oo s o a o c 'O o rt . c ^ Ph , be P r-H 17 S 2 55 .2 c3 ^ r-r hP O c . 0 0 >H 'C -2 . 2 . 0 c , •q-O 0 fl q ^ S 2 ^o 0 aa a 0 3 0 c Cv q; 'O t'* 0 • s es C 3 0 0 0 c 5 Q r-.” c n c> S) 0 0 Ir Sk c 3 < b a 0 0 &i)C •r; cS «? "Hi g'C *2 3 t= > c 5 a H--Q U G 00 tH 0 C c3 .2-3 p ^' c .J- pp tX) s C3 2 o 'C u IS « K to S ■S « P> K £ •’B pi 5 «> K Q S -B 000 o o o o S3 Ci QO Cl 4 J '5 O rt ao a Cl o O O 0000 / ENGAGEMENTS AND BATTLPZS. CXXIX o o to s C'3 §t: .s o «ta kO o K ■geo p4 oT 0 (u <-• p o' - 0 .b'"'p '3 2 a> !s m .2 ® ® s ag p ^4.- a &00 0 0 <; ^ '3 b£ •c cTCh O C 3 to ‘E w oj <5 O . §" S fl O^rg r-i 2< . p p 0 c § w r>> S 5 ^=5*1 'A PI 1 ^ ►••6 cj: c C c > C P .C c O Q § >» § -3 ® -, 3 ; b Si a- »- P s * s o — «n *P 0 gbg ^ p Ph H p 'So o o •3 S . “ 3 a ■r ^ .E P fi 3 C^ flP oJ'*"’ B C ^<3 w b 13 § , o -o ■,T, 3 .1'3! .-: S Q ^ ;g 3 bo ^ a •? 6 g Q rrt h rt P.SO pa® S §5 rt .2 '♦H •St^ o 1-3 < ”1 l a C'> S'S-S o §0 &!>. 0 ? a 1 P I ® kT a> ^ Q.2 -Sts P CO bo ^ •- CQ ® O ^ P ai P > ' > > ^ > ^ > > > > > > ^ > > > > > > > > > > > > o 00 O O B O Z o o o o o 0^0 o o 00 o o o o 00 o 17 * * Killed, wounded, and missing. t Wounded and missing. cxxx CHRONOLOGICAL SUMMARY OF (2.M CD CD o*§ ll Kg . 1 “ 'S o O ^ c rt 'o ^ sa-S o c ei tn c o S 0 o c/5 - ^ G . O «n O) cS rt fl t: o § sk 0-i * o Ox/it- <« &.§ ° D &: ■gK g g,- 3 m K g g a c 3 •l-s’a « cCP® g ^ fcjDJ 3 t* 'P O) _ _-r:> caC-irO’^" Cw ^ « H ^ ^ ^ ^ cj -i-4'Q S 5«Oo =S|ll|s«l , c" s g g^ms feS g g^'S occo _g g a I S >>0 tSfc^.oj^^bCS: "S'^S© -252o^* *S § O !-• P ^ I- I* f^- 5 ) I e ^ P § § ^20 u SQ-I H 5tt trs.\ ^ P P ' •5 ft P P ^ T^> ♦d S H 5£ ; p ? rt g.s> “ is. ^ ^ w o > 2 ft .2 fcD 'C PQ *3 o ■d ©"tn « rt i^S H O rt-P 2Eh p a p Jl '^Z ft ® In ^ O •so >» 'd a> u c'3 is I" Q .® 5 P -- Q ” a CD" P o P W .2 p c g a a o o H -S ft 2 s o 'd O p* ws =--o rt > 3 « O jg '3 S > k'Q CK g '^'3 >“9 •Si 6° © 12 ^ 2 O O) >»§ go <: o .gS '>*p. fl-K >'-p 'p-2 'd b o O c p-5» g>rSrt n j>. < CrP O P '3 ■g » §■ -^i tx.o s 0) O o 3^ " ■2.3 o' “fiS ^h'S .= •- ^-d ««<(<§ wT o 0 ) 'g ® S, r- ^ 3*g P _c* ^ - © ■C © g g 2500 'd 'd © P P 5 *§ p p 5 P 2 o,*^ ft ©©-«-: 2 S ftg §b 8o •5 "3 H *i ;> g^'c S -a M •^ "o ^ rrt «n S 5 S 2 3 lO . p « "d •g §1^ p © *2 »?? C- «■» »'^'d '*- ©Ci C C p > ‘^5'5 ^ JH CO - : ! p p . . © : : ^ d ft p • •g : : Tenn © ■& c ' 6 • © ! ‘C • * Ch 5 : .b d p p *& • * > : £h bB 0 1 ft w ^ ^ p ^ d .K P ft 2 'o ’3 42^ « p bCi 3 ft H . O © o d p p O © !2; ft fcx) O bo ft ft >» 55 ji.d c p ^ P ^ 55 55 ENGAGEMENTS AND BATTLES. OXXXl C3 . §30 B g 0 ^ . •C d rj^ b a 'd Vi 0 2 s *d m 0 d d d g-o >* “ §1 d d 0 d C d .5-- 0 S'g d "d 35 * d 1"” P < e^ 00 ’►J 08 >» P-Ph 0 , Eh S-C . to e3 c ^ tcri i ■55 O M a> c 3 W (w b fan o BO C3 o I o fcJD •c ’3 s? ‘u ho •E « o p, *- o S-* O P ?1 'CJ f 2 a (3 -§!§•" 3 K p^: (d ^ « o o d B O O T-K § -W w 2 'd P C) O "S KKf^g 3 5 ?S? c 3 c t- « S c ^ g « & •B a to ’E « % A c 5 -a 's^lll >4 p .E c 5 S'"! A " «_ d o S C-.2.5 5=3 d .b :*• - d c> Wq c ^ ^ ^ o 2 tfi 5 ^ « .=3 2 c3 S J7 s Q| ^■‘rt d ^ o o 1=3 <3 d 9 o S ^ 'd ^ ta OJ ^3 d >» £ c o ^ g U5 ^ C ^ fe ^ 3 'd O C s -r; O 2 'O '33 >» “ ^ c 3 1 g 'd 3 5 0) i-s ^ o o o rd ^ ' c/ '-' , 2*3 O 3 :2 2 'd ' rt 2 s - 'A= = J O 2 *4-^ d H- si-S-S'^ rt o o ja d d 2 : c CO >» «- H- 2 0) ^ ^ sj d 3 C ■< 'd* W H o 5 § d c w tiH -3 • ^ ^ C K'S '2 ^.a fe 2-g a'K "-=5 2 - O CO HM o-“ si •«a §“ § ° to^ pi^ £-> g .9 ■*" d t==sg . 5 PS g s’ O «t-i C- fe-d ‘S 0 d -.3 J fS o g"® d O V. c . ^ c S^-S = 2 > g 1 =5 g d C ^ d . *3 S S !^ ^ I d c £,=u O *9 ® £ b ^ b u O 'd^ ^'d d a O o •3-« P § a) O r2 00 -d s CO s O £ » - d •“ a J3 o E c d pH ^ 9 ’S ® > s § ?* > fid -d ’to p, [= .S’ S 0^:9 ^ g o ^ d d x2 d 4/ ^ r“H gc^ OJ v: , . to c o S 3 b O PS AS 2 o,^ 23 dCO d'-H d d C Q c ^ £ CO d d d d Q Q B-B P P P P *9 Cl m! -g * Killed, wounded, and missing. CXXXII C^HRONOLOGICAL SUMMARY OF <:|o b lJ cc s 3 a 2 ?. rt S '~l p’'K 2-§;j ^'s. -C* 02 iS ^ c3 i:-=3 5 ! p C2 I .A c -.^ 3h,-£, >, aO “ a' fn O > •S ■" i-ss fc ^ o r-l to ■jf S) §.•= S w i S|| cSrs'rt G c -d o rt c S fl « Q> O he'd ^ a fcr^ be C QO « o ■at, pej H ©a o g-3 ■■3 2 m a o ^ O) ^ bo & a p oo *2 a V ^ ” *H Cu M f*K P ^ ts . O •^ OQ P . cn^ bo C3 - S o llj ■= 5p. ® = • H S !?■= g -a rt ^ n « 'd b,- ^ a S'?!-} p g £ ” w 2 . ?-a Soj o - boa> £ ^ ^ ^ d o p t,*' W osi'd oj o '3'*^ o P:S *3 M ®J2.Si p o •Saissii\[ •papiraojW •P^ICT •SmssiH •papnnoAV T91I13 > i C3 ^ .9 d 'O O °-2 5m o 9 •d S 2 fco o.S "o f*- 03 ^O bX).& p w "gS >» p ^ o .d ^ o p s Bx ^ o « & •d Q, ,p fl C rt Ci ^ :HO d 3 .P W 5'3 « IS gS 5« ^ O fe, I o — •a,2 nS 2 g gS g 2 3 g - £ toa § o g; ^.aooS-a 151 = 0-1 d L uT « p ^ Q W CPCi-O*- ■si® 2 : 2 oo a c r J= 5 •§■■•1 c ^ £ o S p >H S -S d = 25 2 S S cM "I s = p^^'-dOJ ft P d -d 2 rj = .=Jg-ft^ tS ^ I— < d .-H g„-ica^S a g,§tjp5 a § K >> 0 sdocri^jo ?l |o <3 'p 2§ •53 fepq P -p £ i ?5 p .P d o.y o 'P Q 2 as g ® c 'd jdCi o te«a g &’,a S ace gSf,; S 2fS F, o a c" ►,§ •ffl §o •F» U Mi' Jh 3^-90, S'a-B--. <0 .B ■■' '^ “ cci ■■^ ^ C5 tC <*- ,2 *B -rk t. 7 = -^^ iT S ao •i-.-aS^aS a o g .a £ S e-S to 3 « H ^ O g B B &* ..^5 ^ ^ 9 o 'd d 9 fl, J d -ij "§«$,§'3o| 13-s.BCi'§>. g^ccos o 8 d,Q ‘Ed K W : ^ ’t: p^ o OQ.d *p p il d '►C o »> ” = a-p o X « d 2 ® cT w a> P M d O) §g §b 8§ 0“^ £2 « § o p'" p p £ B iH a 6 "O = g P “ page ENGAGEMENTS AND BATTLES, CXXXIII c W . o ■S'l p ':3 fa 'd a 3 O & §d to •§§ p p p p lO p fa O C U O « 2 S fa fa p p fa ^ fcL(s 3 s fa p fa c *p >H fa P fa o '> p o •d p fa p fa O *3 fc- fa p fa O O "3 »-> fa p ^ « a (A 05 p ^ p fa p fa O a fa p fa o fa P fa o fa fa ^"p u bo S-'^ c 3 fa P fa o o § d t .4 .— ^ o rS'z 4 t 4 . 2 . c? d o O p* d u o *p* fa O ^ tn ^ »-• o .o 'S’ .o p* P*p s 8 .o * 3 * ”1 d s ki •+a 3 P ■s . S s d fa s d s p p „ go .2 -S S s o .5 -i w (*H o -faj» o o d be *o d o 8 ® OT o o o « o "S p p ■e o a « ^ u P fa bi 3 ■as g-a ■e o Ph X. 0 01 >3 .a § -d o p 4 i 3 u o CU 3 tH §a p P ^ fco tn O Oh o fa t: o p 4 s I ci^a ^ a p E: t: o Ck >>g M P O fa a'§ p p -p p p o IP 'p p oil® P p p ^ 1 < p l§> fa a *3 |p *fa •r ® C .3 [p "p ’p •0 P [p *fa 8 ‘fa "p 3 a *3 'fa '3 3 8 o fa bo p a fa p 5 g g 6 8 'fa *3 'fa "a ^3 ~ 2 o d '3 *fa p ^ p 8 1 .a 1 a a 8 8 P ' 2 , 8 P 8 fa p 31 § PkCO 8 8 8 8 S d 8 O o O H O o O O o cc O o O p d .C fa ® 2 ■ (-• « fa > £2 cj ^ O fai ^ fa » a c a Sto O ;Ei fclDcS o rt (35 .&s* S< wZ e 'o J 5 & 'S* 0) C3 a 45* go o lit C 3 ■ig go © fQ 5 £ rt o fa .2 o .§5 s 'fa o f-> fa ■gog §5 3 e|« 1 2 9 . b '5 fa o o’ a- ^ So s 'o m 4 ) §*§5 O 0 } fa c « ^ w C* C* ^ Cl Cl fa fa fa 'fa fa fa fa fa fa Q fa fa Q ft p « Q Q P fi P P 0 Killed, wounded, and missing. OXXXIV CHROXOLOGICAL SUMMARY OF o O o ^ a> aiO . S 5 « 3 c &c: o cs o 'o O ^ O s- o i2 I .S -r'W O o -— CSOr ^ r»-' S ® 5 0 2 S3 £ « o ^ S ^ •f £ h - i-So f = o a a. a* O +^ ♦:'3 S, 3 C cy g § g.1 *M S 'S ■S5SO • SuiSf5 ^\[ ■P'^inx •Saissijt • papuuo^^Y O GO O ‘Pouni fC ^ 0) u • ^;:3 o 0-3 CO *3 . fl * — 1 3 SO l1 5^ 3 H CJ »• « C* g g ■gi rt '-* o ^ s§ 3 '3 P fl rt 3 • 33 'S 3 1“ H 2 ^ 3 *31 . ^ 3 b °il =o ^ vQ g 5 ^1 »3 ja P rri rs cc a i^E• 2=5 s CJ fc- 3 V (u o "S «tH ^;a •i g p _ 3 .3 c> « '3 a ^^l!i ■» P : 2 3 p ^ ,2 ~ o ^-a p O ’35 «« S O 'P-r ^ «.:: SoJ a P 3 t, ^ 3 ^ ^^3 ® - 3^:2 '2 u- 5 rrt 3 3 2 uT ^22 “ O.B” ■" ^ ^ ^ 3 2 2 ' 5 . t ! r ^ 0) a a 3 a 3 3 a< ^ -3 0<* t; < >» ^ O 2 S s?: «2 o O j <» P P o o o ® a b o 2 c^ c-* Ph . o 11 = III- bcC ,. t3 2 < 03 III ?'55^ .= a®c: n g . o Sgog ore's* &S &> Q ^ g Q - O ^ ?- «r 3 P CH ®. t3 0 ^ tT ’ sr -^ 4 ) c ^ vs ^ Q («=; S & o .> < o o 'H -P o -2 P=H o t- 'S pnvr b . s p §o o .3 al C4H O 3 ^ e ^ w ^.2 K 'P K S-'H ^3 ENGAGEMENTS AND BATTLES. OX XXV 030 : B fe'3 O M g O 9 o 5 o ■ 2 oj -Ssr) ^ 9 rt ^ III” So li ♦* ► — 03 op- 2 sfSo •S §®12 •Sh 3 .g o £ . rt ^ s s d p: c3 cKco g ^|||§84| § ® g &cO fe-sl sg.l§s^g.g> o S’-S fcn^W O '-3 .-** C5 Cl c g 'C o 5 B “ c g £ •-•§ ^ >• 3 Ch fc. ts ^ £ ^ .3 cc s 5 i • ^ ^ £ S *=8 O I tfiO 00 . o ^ .cj a c5' £*"0 ^ *5 s S >— < £ S.50a! ?.S ^ “s S’g.S t;C.2 a; a c O S >.s| § &” l^£cS'SS'’^-|g 3 -’beg 2 ® S “ g .SliS t' Ttrz'^ ® ® o.2sc“9.xt30 O rt .b" IJ o 55 pC .2 9 o o s ?B _S.o 'ra'.S g.e “SO ■C b •3 SlO e-2 o s’H o i a ° i ^ B.B* c3 C ^ S o s jz; 1 o © xi .':: ■? ^- 1 a 2 b E' S3 ^ cc ■g 2 § § S o I go 'SO ■gaj « PS.; o .2 b sg c3 o S-.^ c3 5 e I .2.'? |S ^ >> o rt t:3 p.^ (S ci a *0 ^ S S o - Cm 0 C-t rt "3 S-B H O B* - O § io <« &• o cs ^ 2) se s o ■K o . ,-M 5:0 ci O •|1 Is "2 1 g8 P.W o _. Wg rs g o o '^' !gO O O .SO a’d <«tz: o _ c 3 o fs% c a> O 0 ) ^ « o I cb £ o u-^ ^ «tM 5 ® *3 B t. t-c %< 11 O '- s“ r > S-l 0 o pp *5* c S .2.6 ® ^g’-M >* ^ 2 I A< c. ^ o © ja pW d: c3 S a o gw P o ^ 03 ,©•= I’ ^ P d 2^ O ■5 o w 2 © © k. d iJ3 a o O p 5 t: 3 <5 c *b o Eh 5 5 5 Sr3 ^ Ph P Killed, wounded, and missing. t Killed and wounded. CXXXVI CHEONOLOGICAL SUMMAEY OF ®o t: • o ^ ^ 1 ;; •- ^ ig '3 o ^ ^ C3 ^|s 1^1 £ ES'S c b ^ t 3 t: C5^ o (A O C 3 r> ui cS «M . o w p< ^ o -*- pH .2 o cc p- ^ o +- S3 SS « o «o ®6 P5-: i-> ” ie « o e a o o •Suissipi ■papunOj\\^ •pail'JI •suissiH ■papunOjW •pallia o o o 0 'c? l-js o » »<=■§ &C3 a ^ S ® rt3 <=3 ja *3 X <*-l £ o o Sb 4 P I— ( M f ^ £ S S' >P QJ O d > ^ a a OP q8 ‘J ^ a P C3 a o 5 i S 2 rt o -^3 " Ci 0^3 'o b o § B'^ i 2 « a? ''a A 33 ^ a *b a» o ^ Q.t.B ® O r'j 4 ^ 5'^' 3 -sl^ 3 ^ : a 9 p >» esi p t>» o ^ o a . 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'w T T ^ i- -2 t be 5 ^ ^ S t ^^rtpgr .^QWSC&udO-« : C3.-- s ^ w ^ o ■= = o S rt go r«*=I o 'd a s c d o fee P a o o o ^ a iS a = "= H I • a. a ® p M'Sb g= > !=B 9 d d S *2 d d ^ 5 4 ua d ^•5) 20 a ^ J3 o '3 18 * Killed, wounded, and missin". f Killed and wounded. CXXXVIII CHRONOLOGICAL SUMMARY OF -3 O -bl =3 '3 . C< g S CL '♦3 <; b Os h’g o p ’-w; iJD ed G t . O t:r; ^■g '5 ^ o b d J'^6 SrtCC P^o ^ r’bx)1o “•a-b S§| pifS a II" SSj:; — ■g ? a p Sf SPh g, g3 p C.M ” Pl •C*^o PQ P. <: to a •E s 'C a5 SiS gCi a; •— > tL*E c 3 Dd w > Ot M O u IC a .2 2 “a . a Sai I “R a ‘3J'’ 33 gj'C o O o, »w<; --c S' »rt o a i ® g 11^ o S 5 'd O o G ,« 2 s P. 5 p O flj 2 i:'d t g a a •3uiSSII\[ •papuuoAV •psilDI ■Suissiitt •pDpunojW •psiUH wa cj-sj 1*^ I ^ O a) S.o § K§ a ags -=3 0® •55 £ 12 :B‘e'S 0.25 CO ^ K .► c3 • fW s ^ o a ^ O 0) G <50 1 ..r u a^ 0 . 2,0 *« P l- -a B“„- =■' = a a 2 >>2 PSP G 2 a-«~ •a to ;e| b Q a S .«o<) 2 a g g =, ^ G ® g c? uT ji S ^ O 00^ ir".- a^ • ® 2 oSO'g ^ 2 g to a 0^8 PJ 5 ^ ^ :.e a ci f-> < 2 ’3^ G olisg ^-q5 I g‘s s’^ G O . c ®’E ^0 3^ -i^.2 O 01 o W *33 S O ‘3 ® ■C a .C o 0:2 ‘t' 2 I r, -G O p ^ p p' . a .^-Ea G o -5 O 5 j 02 0£ . o .,.2 P.! a> ^ d a. ^--<5 •— ."t; ® 2 .2 gfi Sa % .2 o ^ a; , p .■:M«3 oO a ^1 . 0 G Og iT^ ’& a.S 'd 0 P. G ‘S bCffTw §fl 0 — G |§ tH 0 -p o G - .^P. (3 o Q5 ^2*0 1 & "lo tti^ 0.2 o g.a •s s a wo-s s|l a c-a 0^.a G .2 o^g -d o a a a &0.2 "S t .ts o.°.& p"g o •i -b •E§s Ih g II O g p P ® o O « . p io.| .&b^ c's !2 g S .£5S oO G Cl o a 0:2 “3 cT ^G p -2 2^ 02 •E b wo •P W' ® -=3 05* ^3 !>.b® 2 p ^ S 5 K ® e J is” tM ^ ^ o o <-S^i^s- a . a ..“O cOSOo . OKO g'g^ g o .00 „ u S c?t, a m . 2, 2 S O g &3 S .Vg 5 '=> 0 § 3 iS ^ m- a a oT a 'O CL O o P. O o o 1" O O 0 “ ooSPhOS o G ^ a >.5 *2 o gW p a 1 1 >-E W-a — w o I o PhS sS a t> a 3 o W .3 .2 > S 2 bo o B •S .3 I ‘I < < ENGAGEMENTS AND BATTLES. CXXXIX i a" ^ •3 •§ J ’3 *C ^ ‘E ^ ^ E c> tc S ■I 1 x 3 -' 3 bd Do .■i^ ^6 .“d W CO . ^ '■'p Hi . w . c o C > a c " cs o c3 s c fc£) d. to O ‘S PS o .2 S O rt o cj. '30C-S ^'bo'S^ oJ •e i3 , rt •*> A- 3 ,= 4i 3 I ii ^ 3 .2 g Q S“6 S'g P. 3- ^ o c S o O u a <: s ^ ^ « £0 c 0 . 2 -^ Hi tc g f: rH 3 P bP c3 -a § ?'^r « ^ is* ph . a o a'-o p-OQ » bo bo'C C3 Q- H bo Be G o bJDCi p'l, . O O £-5i ^ GJ '3 2 O . ^ 5 E* o o .J rt ft O Pi >* (m rt 'ft 'gg B| p «M .£0 .2 c ^ £ 5 1 ? Q 2 as U o b 15 8i ^ B ^ o go So rC ^ ® §«a 'aeS |i-< £ 9* - SE .H ,G u . O . •-H c:-3g ti ® o o c a o ^•s- « £ ^3 ,2 o ft '> 2 5 1 3® >. - (1 P C3 o .t: ss ^ ^2 o o J o 5 ® bO-.fl •E Pi « £ ->4 Pi O »— t, M *- p o o o VPh ZJ e*** bOaT ‘S P o -O >. S tN c a ® ^ i*Si <^6 .2 o in ^ J3 -S o P ip ft a CO « _ *^ S 'O o a p ^'ft „-s & ^ ^ '55 "o o ft-;r p Crt 2’2 o ir -2 0} ii e p3 P • 5 ; Pi o s 03^ ^ >» . t-i .P 'O S.P 2 r P .Sf o •« 0.2 .£P O n o «.P t.i ■*-• ^ft P) to ► Pi ® j? 'O O p O bO^ .P *E ^ Pi CC ^ 9i rt'S t o O P.P P gi c Pi 3 S 5-1 0.2 ,14 © sa P.2 o 2 ! 2 *^ 5": ■*^ fH 5^ fci ^ ft C3 ® Hi « oT ^ irt O «o bo , .p 'E Pi P3-^.& O 3^ PS Pi © P£ ct O 03 g j5 Q 'S' p- <: g> > to > to g O 3 s “ o < © M P -T ^ e? P O P cT p a p 0 3 t S © © a .05 2 i fri 0 w 9 » rt a s B 0 Pi Pi B "tS 0 © © © j © 3 © 0 ■& p 0 rant! lina. 1 0 H ■c 0 XX, CXL Chester Gap, Va • LXII, LXXXIV Chester Station, Va CV'I, CXXIX Chesterfield, S. C CXXXV I Chapinansville, \V. Va XXXVII Chapel Hill, Tenn LXVTII CXLTV INDEX Page. CuAM’iON Hills, Miss LXXV, XCVII Chapin’s Farm, Va CXXV Chambersburg, Va CXVIII Charles City Cross Roads, VA L, XCIII, CXII, CXXV Cliantilly, Va LVI Chancellorsville, Va LXXIV Chackahoola Station, La LXXIX Chattanooga, Tenn LXXXV, XCIII, CXXXI, CXXXVI Chattahoochie River, Ga CXVI Cheese Cake Church, Va XL Cherokee Station, Ala XC, XCI Cheek’s Cross Roads, Tenn Cl Cherry Grove, Va CIH Chewa Station, Ga CXVII Cheraw, S. C CXXXVI Chickamicomico, N. C XXXVIII Chichahominy, Va XLVII, L, CVHI Chickasaw Bayou, Miss LXV Chickamauga, Ga LXXXVII Childsburg, Va CVII Chickasaw, Ala., to Macon, Ga., Wilson’s Raid CXXXVII Church in the Woods, Mo LIII Chuckatuck, Va LXXII Chunky .Station, Miss XCVIII City Belle Transport, La CV City Point, Va CVI, CXIX Civicjues Ferry, La LXXIV Clark’s Hollow, W. Va XLVI Clarendon, Ark LIV, Cl, CXIV Clarendon Road, Ark LXVI Clarksville, Tenn LV, LVII Clarksville, Ark XCI, XCII, CXXV Clarkson, Mo LXI Clark's Neck, Ky LXXXV Clara Bell transport. Miss CXVII Clay County, Mo LXXVI, CXV Clear Creek, Mo LIII, CVHI Clear Springs, Mo CXVIII Clear Lake, Ark CXXXVI Clendenin’s Raid below Fredericksburg, Va LXXVI Cleveland, Tenn XCIV, XCV, CII, CHI, CXX Clinton, Miss XC, XCVII, CXV, CXVI Clinton, La LXV, LXXVII, CV, CXXI, CXXXVI Clinton, N. C XLVI Clinton, Ga CXXIX Clinton, Mo LI Clinton County, Mo XXXIX Clinton Creek, La CXXIX CUnch River, W. Va XCIV Clinch IMountain, Tenn XCIV Cloutersville, La CIV Cioyd's Mountain, Va CVII Columbus, Mo XLI, LII Columbus, Ky CXXXIV Columbus, Ga CXXXIX Columbia, S. C CXXXV Columbia, Tenn LVII, CXXX Columbia, Kj' LXXXI Columbia Bayou, La CXI Cobb’s Point, N. C XLI Cochran’s Cross Roads, Miss LVII Coffeeville, Miss LXVIII Coggins's Point, Va LIII Cold Harbor, Va L, CXI Coldwater, Miss LII, LVII, LXII, LXIII, LXVIII, LXXII, LXXXIV, LXXXV Coldwater Grove, Mo CXXVIII Cold Knob Mountain, Va LXIII College Hill, Miss CXXI Cohnan’s, Miss C, CXV Colliersville, Tenn LXXXIX, XCI, XCV ColUersville, Miss CXIV Comfort, N. C LXXXI Como, Miss LXXXIX Page. Combahee River, S. C CXXXIV Construction train ^ear Murfreesboro’, Tenn..., LXVII Convalescent Corral, Miss LXXXII Concha’s Spring, N. Mex LXXXIV Conee Creek, La CXXI Congaree. Creek, S. C CXXXV Coosaw River, S. C XL, CXXXI Coohomo County, Miss LIII Coon Creek, Mo LV Coosa River, Ala CXVI Corinth Road, reconnoissance on. Miss XLV Corinth, Miss XLVI, LIX, LXXXII, CXII Corinth, Miss., evacuation of XLVII Corydon, La LXXXII Com-tland, Tenn LV Courtland, Ala CXVII Courtland Bridge, Ala LH Courtland Road, Ala CX Cosby Creek, Tenn XCVI Cotton Plantation, Ark LI, CIV Cotton Hill, W. Va LVH Cotton Gap, Ark LXXXVI Cottage Groove, Tenn J.XIX Cove Creek, N. C LXIII Cove Mountain, Va CVH Covington, Tenn LXIX Cow Skin, Mo CXIX Cow Creek, Kas CXXIX Coyle Tavern, Va LXXXV Coxe’s Bridge, N. C CXXXVII Cross Lanes, W. Va XXXVI Cross Keys, Va XLVill Cross Hollows, Ark LXI Cross Timbers, Mo XC Crump’s Landing, Tenn XLHT Crump’s Hill, La CII Crab Orchard, Ky LV Crawford County, Mo LXIII Crawford County', Ark CXIX Craig’s Meeting-House, Va CV Crew’s Farm, Va LI Creek Agency, I. T XCI Creelsboro’, Ky , XCIV Crooked Creek, Ala LXXIII Crooked Run, Ohio CIX Crooked Run, Va CXX Cripple Creek, Tenn LX XV Culpeper, Va LI, LXXXVII, LXXXIX, XCII Culp’s House, Ga CXIV Cumberland, Md CXIX Cumberland River, Ky XLI Cumberland Mountains, Tenn XLIII, XLVI Cumberland Mountain, W. Va XLVI Cumberland Gap, Tenn XLIX, LXXXVI, XCVII, XCIX Cumberland Iron Works, Tenn LV, LXVII Cuyler's Plantation, Ga CXXXII Cypress Bridge, Ky XXXIX Cypress Bend, Miss. River LXXIX Cypress Swamp, Ga CXXXI Cynthiana, Ky LII, CXII Dabney^’s Mills, Va CXXXV Dallas, JIo XXXVI, LV Dallas, Ga CX Dallas, N. C CXXXIX Dalton, Ga XCVI, CVH, CXX, CXXVH Dam No. 4, Potomac, Va XL Dandridge, Tenn XCVI Danville, Ky LXIX Danville, Ark 01 Darbytown Roads, Va CXXVI, CXXVH Dardanelle, Ark LXXXVI, CVII, CXXXIV Darkesville, Va CXVII, CXXIII Darnestown, Md XXXVII Davis’s Farm, Va CXIV INDEX CXLV Davis’s Miss Davis's Cross Koads, Ga . . . Da 3 *'s Gap, Ala Decatur, Ga Decatur, Teun., near Decatur, Miss Decatur, Ala Deer Creek, Miss Denmark, Tenn Dent Count}', Mo Dcs Alleinands, La Des Arcs, Ark Dead Buffalo Lake, D. T . . Deatonsville, Va Denver, C. T Deep Bottom, Va Deep Bottom Run, Va Deep River Bridge, N. C . . Deserted House, Va Devil s Backbone, Ark Devaux's Neck, S. C Diamond Grove, jMo Dinwiddie Court-house, Va Ditch Ba^’ou, Ark Dobbin's Feriy, Tenn Dodge Count}’, Mo Dog Walk. Ky Donaldsonville, La Doniphan, Mo Doubtful Canon, A. T Douglas Landing, Ark Dover, Tenn Dover Road, N. C Downer’s Bridge, Va Draft Riot, New York City. Drainesvillc, Va Dresden, Ky Dripping Springs, Ark Driver’s Gap, Ala Droop Mountain, Va Drur}''s Bluff, Va Dry Forks, Iffo Dry Forks, W. Va Dry Wood, Mo Dry Creek, Ala Dutch Gap, Va Dutch Mills, Ark Dug Springs, Mo Dug Gap, Ga Duck River Shoals, Tenn . . Duck Run, Tenn Dukedom, Ky Dunbar's Plantation, La .. . Dumfries, Va Dunksburg, Mo Dunn’s Bayou, La Dunn’s Lake, Fla Durhamviile, Tenn Dutton’s Hill, Ky Duval’s Bluff, Ark Duvall’s Mills, Va Dyersburg, Tenn Eaglevillc, Tenn East Pascagoula, Miss East Point, Miss Ebenezer Church, Ala Ebenezer Creek, Ga Eden Station, Ga Edgefield Junction, Tenn . . Edisto Island, S. C Edwards’s Ferry, Va Edwards’s Station, Miss Eg\’pt Station, Miss Klkwater. W. Va 1!>» Page. LXV LXXXVI LXXIH CXVII.CXIX LII XCVIII C, CIV, CX, exx, CXXVllI, CXXXIII LX VIII, LXIX LVI XXXIX LVII LXVI,CXVH LXXXIV CXXXIX cm CXVII, CXVIII exx CXXXIX LXVII LXXXVI CXXXI XLV CXXXVIII CXI LXIV LUI LX LXXX, LXXXIII, XCVIII, CXIX XLIII, CXXIII CV CXXXVI XLI LXXIII CIX LXXXIII XXXIX, XL, XCIX XLVI LXV LXXIII XCII evil XXXIV XLI XXXVII LXXXV LXXXIV, exm, CXXIII GUI XXXVI LXXXVI, CVI LXXII exxx c LXXI LXV XL CV CXXXV LVIII LXX LXVI, XCIV,CXXI CXXXI LXVII LXVIII LXXI ^ CXXVI CXXXVIII CXXXI CXXXI LV XLVI XXXIV, XXXVIII LXXV CXXXIII XXXVII Elk River, W. Va Elk River, Tenn Elk Fork, Tenn Elk Shute, Mo Elkton, Ky Elkton Station, Ala. . Elkliom Tavern, Ark Elkin’s Ford, Ark Elizabethtown, Ky . . . Elliott Mills, Mo Page. EVJI LXXXI, LXXXIII LXV , CXIX CXXXII XLVI XLII CU ...LXV, CXXXIII XXXVII Ellison's Mills, Va Eltbam’s Landing, Va . . Estill County, Ky Evlington Heights, Va. - Ezra Chapel, Ga Fairfax Court-house, Va. Fairfax Station, Va Fairfield, Penn Fairburn, Ga XLIX XLVI LXXXIV LI CXVIII XXXIV, LI, LXIX, LXXX CXXIII LXXXI exx Fair Gardens, Tenn Fairmount, W. Va Fair Oaks, Va I’alliug Waters, Va Falmouth, Va Farmington, Miss Farmington, Tenn Farmville, Va Farr's Mills, Ark Fayette, Mo Fayetteville, Ark Fayetteville, W. Va Fayetteville, Tenn Fayetteville, N. C Federal Point, N. C Fishing Creek, Ky Fish Springs, Tenn Fish Bay, Ark Fisher’s IHll, Va Fitzhugh's Crossing, Va Fitzhugli’s Woods, Ark Five Points, Va Five Forks, V.\ Flat Lick Ford, Ky Flat Shoals, Ga Flint Creek, Ark Flock's Mills, Md Florida, Monroe County, Mo Florence, S. C Florence, Ky Florence, Ala Floyd's Fork, Ky Floyd County, Ky Fort Abercrombie, D. T Fort Adams, La Fort Anderson, Ky Fort Anderson, N. C Fort Blair. Ark FORT Blakely, Ala Fort Blunt, 1. T Fort Brady, Va Fort Burnham, Va Fort Cobb, 1, T xcvn LXXIII XLVIII, CXXVIll XXXIV, LXXXIII XLVI XLVI LXXXIX CXXXIX CXYI CXXIV LII, LXI, LXIV, LXXII, CIX, CXXVIll LVII, LXIII, LXXV XCI CXXXVI CXXXV XLI, LXXVI LXVII CXI eXX, CXXIV, CXXVI LXXIII Cl XCV CXXXVIII XLI CXVIII c CXIX XLVn, LII CXXXVI LVIII Lxxvii, xcvi, cm, CXXVI LIX LXXX LVII CXXVI Cl CXXXV LXXXIX CXXXIX LXXVI CXXXIV CXXXIV LXI Fort Craig, N. Mex Fort Cottonwood, Nev FORT DARLING, VA Fort Davidson, Mo Fort Do Russy, La Fort Donelson, Tenn Fort Esperanza, Tex Fort Fillmore, N. Slex FORT Fisher, N. C FORT Gaines, Mobile Harbor, Ala Fort Gibson, I. T Fort Gilmore, Va ...XXXVII, XLH.XEVII CXXII, CXXIII XLVI, CVH CXXIV Cl XLI, LV, LXVII, CXXVI XCIV XXXV, LIV CXXXIII, CXXXIV CXIX LXXVI, CXXIII exxy CXLVI INDEX Fort Halleck, 1. T Fort Harrison, Va Fort Hatteras, N. C Fort Heinian, Tenn FouT HENtiv, Tenn Fort Hill, Vicksburg, Miss Fort Hindman, Ark Fort Jackson and St. Philip, La Fort Johnson, S. C Fort Jones, N. G Fort Kelly, AV. Va Fort Leavenworth, Kans Fort Lyon, I. T Fort Lyons, Va Fort McAllister, Ga Fort McCook, Ala Fort McRae, N. Mex Fort Macon, N. C Fort Morgan, Ala Fort Myers, Fla Fort Pemberton, Miss Fort Pickens, Fla Fort Pike, La Fort Pillow, Tenn Fort Pulaski, Ga Fort Rice, D. T Fort Ridglej^, Minn Fort Sanders, Tenn Fort Scott, Mo Fort Scott, Ark Fort Sedgwick, Va Fort Smith, Ark Fort Steadm.vn, Va Fort Stevens, D. C Fort Sumner, N. Mex Fort Sumter, S. C Fort Taylor, Ga FORT Wagner, S. C Fort Wright, Tenn Fort Brown Road, Tex Forsyth, Mo Forty Hills, Miss Fosters Bridge, N. C Foster's Expedition, N. C Fourteen Mile Creek, liliss Fox Creek, Mo Frankfort, Va Frankfort, Ky Page^ LXXXli CXXV XXXVI CXXVIII XLI LXXIX.LXXX LXVI XLVI XLIX.CXV CXXXV CXXX CXXVII CXXXII Lxxvn LXVH, LXVIll, CXXXII LV LXXIX XLVI CXIX,CXXI CXXXV LXTK XXXIX LXIII XLA^ XLVI, XLVHI, Cl, CHI XLV CXXV LV XCIV XXXATI LXXXVHI CXXV,CXXIX LXXXVI, CXVHI, CXXI cxxxvn CXVI xcv XXXIV, LXXI, LXXXVI CXXXIX -LXXXII, LXXXIII, LXXXVI XLVHI LXIV XXXV, LIII LXXIV CXXXII LXIV LXXV XLII LXIII CXI Filvnklin, Tenn LXIV, LXVII, LXIX, LXX, LXXIII, LXXVII, CXXII, CXXX, CXXXIII Franklin, Mo CXXV Franklin, Miss CXXXIV Franklin, Va LIX, LXI, LXIII Franklin, La LXXVl Franklin’s Crossing, Va LXXVII Franklin County, Ark LXXXVHI Franklin Creek, Miss CXXXIII Frazier’s Farm, Va L Frederick, Md LVII, CXVI Fredericksburg, JMo CXVII Fredericksburg, Va XLVI, LXII, LXIV, LXXVl Fredericksburg Road, Va CVIII Fredericktown. Mo XXXVIII Freeman’s Ford, Ya LV Fremont’s Orchard, C. T CIII French Broad, Tenn XCVII Front Royal, Va XLV1I,CXX Front Royal Pike, Va CXXIV Frying Pan, Va LXXVII Fulton, Mo XXXV Fulton County, Mo UII Funkstown, Md LXXXII Gaines’s Mill, Va L, CXI Gainesville, Va LVI Page. Gainesville, Fla XCIX, CXX Gallatin, Tenn LIV, LIX Galveston, Texas LXVI Garrettsburg, Ky LXII Gaulcy Bridge, AV, Va XXXIX Geiger Lake, Ky LVII Genesis Point, Ga LXVII, LXVIII Georgia Landing, La LXI Georgia, Raid in CXVI Gei-mantown, Tenn XLVHI, XCVIII Gettysburg, Pa LXXX Ghent, Ky CXXH Glade Springs, Va CXXXII Gladesville, A^a CXXV Glasgow, Ky LX, LXV, LXXXVHI Glasgow, Mo CXXVII Glendale, Miss XLVI Glendale, A^a L Glorietta, N. Mex XLIII Gloucester, A’a LXIII Gloucester Point, A'a LXVII Golding's Farm, A^a L Goldsboro’, n. C LXIV, CXXXVII Golgotha, Ga CXllI Goose Creek, A’^a LATH Gordon s Landing, La LXATII Gordonsville, Va CXXXI, CXXXIII Gov. Moore's Plantation, La CV Grafton, AV. A’a XXXVI Grahamsville, S. G CXXX Grand Lake, Ark - XCIX Grand Haze, Ark LI Grand Prairie, Ark LI Grand Prairie, Mo LXI Grand River, Mo LIV Grand Gulf, Miss LXXIII, XCVI, CXVI Grand Pass, I. T LXXXII Grand Coteau, La XCI Grant's Creek, N. C CXXXIX Grass Lick, W. A’^a XLAT, CVII Gravel Hill, A^a CXX Gravell}’’ Run, A^a CXXXVII Graysville, Ga LXXXVI, XCIV Great Bethel, A’a XXXIV, XLIII Great Falls, Va XXXV Great Cacapon Bridge, Va XLI Greasy Creek, Ky LXXV Greenville, Mo lAI Greenville, N. C XCIII, XCV Greenville, Miss LXA'HI Greenville, Tenn CXXIII, CXXVII Green Bridge, AA^. A'a XXXA’^II Green's Chapel, Ky LXV Greenville Road, Ky LXII Greenville Road, N. C XLATII Greenland Gap, AA^. A^a LXXII Greenland Gap Road, AV. Va CXI Green Springs Depot, Md CXIX Greenwich, A’a LXXVII Greencastlo, Pa I^XXIX Green River Bridge, Ky LXXXI Gregory's Farm, S. C CXXXI Grenada, Miss LXXXV GriswoUlville, Ga CXXIX Grosse Tete Bayou, La XCIX, Cl Ground Squirrel Church and Bridge, Va CATI Groveton, A’a EVI Guerrilla Campaign in Missouri LIV 1 Gum Swamp, N. C LXXVl I Gunter's Bridge, S. C CXXXV ' Guyandotte, AA''. A’'a XXXIX Guy's Gap, Tenn LXXX Hampton, Yu XXXVI Hampton Roads, Va XXXII INDEX. OXLVII Page. IIauper's Perry, Va XXXIV, XLVII, LVII, LXXXVIII Harper's Ferry Bridge, Va JjXXXII Harper's Farm, Va CXXIX Harpeth River, Tenn LXVIII, LXXI Harrisonville, Mo XXXV, LXII Harrison s Island, Va XXXVIII Harrison s Handing, Va LUI Harrisonburg, Va XHVIII Harrisonburg, La C Harrison, Mo CXXV Hairisburg, Pa LXXX Han'odsburg, Ky LX,CXXVII Hartsville, Tenn LXIV Hartville, Mo LX VI Hartwood Church, Va LXIII, LXVIII Hartford, Ky LXXVI Hamilton, N. C LI,CXXXII Hamilton, Va CXXXVII Hanover, Pa LXXX Haxoveu Court-house, Va XLVII, LXXX, CX Hanoverton, Va CX Hancock, Md XL Hanging Rock, W. Va XXXVII Hankinson's Ferrj-, Miss LXXIV Hawk s Nest, W. Va XXXVI Hatchie River, Tenn LII Hatcher'S Run, Va CXXVIII, CXXXI, CXXXV Hall's Ferry, Miss LXXV Halltown, Va LXXXIII, CXXI, CXXH Hager's Mountain, Md CXVI Hagerstown, Md LXXXI, LXXXH, CXV Ilaguewood Prairie, Tenn LXXXVHI Half Mount, Ky CHI Hammack's Mills, W. Va CXV Half Moon Battery, N. C CXXXIV Hardy County, W. Va LXVI Harney Lake Valley, Oreg ClI Hatteras, U. .S. Steamer LXVI Hawe's Shop, Va CX, CXI Haxal's, Va LI Haymarket, Va LX Haynesville, Va XXXIV Hazel Bottom, Mo LX Hedgeville, Va LXI, XC Helena, Ark LIV, LVIH, LX, LXIII, LXVI, LXXVI, LXXXI Henderson Hills, La Cl Henderson's Mill, Tenn LXXXIX Henderson, Ky' CXVII, CXXFV Hendricks, Miss LXXXVII Hernando, Miss LXXII, LXXIX Henrytown, Mo XXXVHI Hicksford,Va CXXXII Hickory Grove, Mo LVIII Hickman, Ky LV High Bridge, Va CXXXIX Hillsboro’, Ky XXXVHI Hillsboro’, Ga CXIX Hillsborough, Ala LXXI Hill's Plantation. Ark LI Hill's Plantation, Miss LXXIX Hill’s Point, Va LXXII Hodgeville, Ky XXXVHI Holly River, AV. Va XLVI Holly Springs, Miss LXHI, LXV, CIX, CXXH Hollow Tree Gap, Tenn CXXXHI Holland House, Va LXXV Holston River. Tenn XCHI, XCIX Honey .Spring, I. T LXXXIII Honey Hill, S. C CXXX Hoover's Gap, Tenn LXXIX Hopkinsville, Ky CXXXII Horse-shoe Bend, Ky LXXV Horton's Mills, N. C XLVI Hot Springs, Ark XCVII Page, Howard County, Mo LVI, CXXH Howe’s Ford, Ky LXXHI Housatonic, loss of, S. C XCIX Hudnot's Plantation, La CV Hudson, Mo XL Hudsonville, Miss LXII Huff’s Perry, Tenn XCH Hunnewell, Mo XL Humonsville, Mo XLHI, XC Huntersville, Va XL Huntsville, Ala XLV, CXXV Huntsville, Tenn LXII Hurricane Bridge, W. Va LXX Hurricane Creek, Miss CXX, CXXI, CXXVIII Hutchinson, Minn LVII Hlinois Creek, Ark LXIV Independence, Mo XXXIV, XXXIX, XLH, XLHI, LFV, LXVH, CXXVHI Indian Bay, Ark CHI Indian Village, La LXVH Indian City Village, La CXIX Indian Ridge. La LXXI Indiantown, N. C XCV Ingraham's Plantation, Miss. . . Ingham’s Mills, Miss Ironton, Mo IRISH Bend, La Irwinsville, Ga IiA'ine, Ky Isle of Wight Coiu-t-house, Va Island No. 10, Tenn Island No. 76, Miss Island Ford, Va lUKA, MISS XXXIX LXXXIX XXXVH, XXXVHI, CXXIV LXXI CXL LXXXIV LXV XLV XCVI CXVH LVIII. LXXXH Ivy Ford, Ark Ivy Ford, Ky , Ivy Hills, Miss Jackson, Tenn Jackson, miss Jackson, L.a Jackson Cross Roads, La Jacksonville, Fla Jacksonport, Ark jaebsboro’, Tenn Jack's Shop, Tenn Jack's Shop, Va James City, Va James River, Va James Island, S. C JaiTett's .Station, Va Jefferson, Tenn Jefferson City, Mo Jeffersonton, Va XCVI CXXXIV XCIX LXIV, LXXXHI LXXV, LXXXH, LXXXHI, CXV CXXVI, CXXIX LXXIX LXX, CV XCV, CIV XLH LXXXVII CXXXHI LXXXIX . .XLVI, LXXXIV, CVI, CXIII, CXXVIII XLVHI, XLIX, LXXXHI, CXV, CXXXV CVH LXV CXXVI LXXXIX Jeffersonville, Va Jenkins’s Ferry, Ark Jenk’s Bridge, Ga Jennie's Creek, Ky Jerusalem Plank Road, Va . . Johnstown, Mo Johnson Depot, Tenn Johnson’s Mills, Tenn Johnsonvillc, Tenn John's Island, .S. C John Day’s River, Oreg Jonesboro’, Mo Jonesboro’, Ark JONESBORO’, Ga Jones’s Bridge, Va Jones’s Ford, Jliss Jones's Hay .Station, Ark .Tonesville, Va Jomado Del Muerto, N. Mex. .ludah. Rebel I’rivateer Julesburg, I. T evil CV CXXXI XLI CXIV, CXXHI XXXIX LXXXVII XCIX CXXIV, CXXIX CXV CXXXIX XXXVI, LXXXIX LllI CXXI, CXXH, CXXIX CXIV LXXXH CXXI XCV LXXVHI XXXVI CXXXIV OXLVITI INDEX \ Kearnstown, Va Keurneysville, Va Kearsarge and Alabama, off France Kelly’s Island, Va Kelly’s Foi'd, Va Kelly's Store, Va Kellar’s Bridge, Ky Kenesaw IMountalv, Ga Kentucky River, Ky Kettle Run, Va Keytesville, Mo Kincaels, Tcnn Kilpatrick’s raid in Virginia Kilpatrick’s raid in Georgia Kinderhook, Tenn Kikston, N. C Kingston, Tenn Kingston, Ga King George County, Va King George Court-house, Va King’s School House, Va lung’s River, Ark Kingsport. Tenn Kingsville, Mo Kirks ville. Mo Knob Noster, Mo Knoxville, Tenn •. Kock's Plantation, La Lavergne, Tenn Labadiesville, La Lacey’s Springs, Va Ladija, Ala Lafayette County, Mo Lafayette, Tenn La Fourche Crossing, La La Grange, Ark La Grange, Tenn Lake Providence, La Lake City, Fla Lake Chicot, Ark Lamar, Mo Lamar, Miss Lamb's Ferry, Tenn Lamine Crossing, 3Io Lancaster, Mo Lancaster, Ky Lane’s Prairie, Mo Lanquelle Ferry, Ark Lauderdale Springs, Miss Laurel Hill, W. Va Lattemore's IMills, Ga Lawrence, Kans Lawrence County, Ky Lawrenceburg, Ky Luwrenceburg, Ohio Lawrenceburg, Tenn Leatherwood, Ky Leavenworth, Ind Lebanon, IMo Lebanon, Tenn Lebanon, Ky Lebanon, Ala Leesburg, Va Leesburg, ISIo Leesburg Road, Va Lcetown, Ark Leetown, Va Lee’s Mills, Va Lee, Surrender of Legate s Point, S. C Legaresville, S. C Leiper’s Ferry, Tenn Lowisburg, Va Lewisburgh, Ark Page. XLII, CXVII CXXI CXIII XXXIV LV, LXIX, LXXXIV, XCII, XCVII LXVII CXII CXI,CXIV LXII LV XLII XCII c CXXI LTV LXIV, CXXXVI XCII CIX LXXXV LX III XLIX cm cxxxii cxn LIII XLI . . . . LXXXVI, XCIII, XCIV, XCVII LXXXIII . . -LX, LXni, LXIV, LXVI, CXXII LXI CXXXIII cxxvm jtLIlI, CXII XCV, CXI, CXIV, cxv LXXIX , . . . LVn, LX, LXII, LXVI, LXXIV Lxn, LXXI, cxv LXVII, LXXVU, LXXVIII, LXXX XCVIII CXI LXII LXIII CXXXIII LXXXIX XXXIX LX XXXV, CX LIII XCIX XXXV, exxv CXIII LXXXV LXXXV LX LXXXIII xci, exxx LXII LXXIX XLIII XLVI, LXII, LXIII, LXVII LI, LXXXI, CXVIII XCVII XXXVIII exxv LVIII XLII CXV XLV, CXVI, CXVIII CXXXIX XLVIII XCV XCI XLVII XCVI LewinKville, Va Lett’s Tan Yard, Ga Lexikgton, mo Lexington, Ky Lexington, Tenn Lexington, W. Va Ley’s Ferry, Ga Liberty, Mo Liberty, Va Liberty, La Liberty Gap, Tenn Liberty Mills, Va Liberty Post Office, Ark Liberty Creek, La Licking, Mo Licking River, Ky Lick Creek, Ark Limestone Station, Tenn Linden, Va Linden, Tenn Linn Creek, Va Linn Creek, Mo Little Bear Creek, Ala Little Black River, Mo Little Blue, Mo Little Blue, D. T Little Cacapon, Va Little Creek, N. C Little Harpeth, Tenn Little Missouri River, Ark . . , Little Missouri River, D. T . Little Osage River, Kans . . . Little Pond, Tenn Little Red River, Ark Little River, Tenn Little Rock, Ark Little Rock Road, Ark Little Rock Lauding, Tenn . Little Santa F6, Mo Little Tennessee River Little Washington, Va Liverpool Heights, Miss Lock’s Ford, Va Lockridge Mills, Ivy Lotspeach Farm, Mo Logan County, Va Logan Cross Roads, Ky Lone Jack, Mo Long Prairie, Ark Longview, Ark Lookout Station, Mo LOOKOUT Mountain, Tenn Lost Mountain, Ga Loudoun County, Va Loudoun Heights, Va Louisa Court-house, Va Louisv'ille, Tenn Lovejoy Station, Ga Lovettsville, Va Low Creek, AV. A'a Lowndesboro’, Ala Lucas Bend, Ky Lumkin’s Mills, Miss Luna Landing, Ark Lundy's Lane, Ala Luray, Va Lynchburg, Va Lynch Creek, S. C Lynnville, Tenn McAtee’s Cross Roads, Ga . . MoConuellsburg, Tenn McCook's raid in Georgia . . . McDowell, Va McLean’s Ford, Va Page. XXXVII LXXXVII XXXVI, XXXVII, XLin, CXII, CXXVII LX, LXXXIV, CXII LXIV CXI, CXII evin LX exm cxxix LXXIX xc cm CXXIX XLVI CXII LXVI LXXXVI XLVI LXXV XLI xxxvm LXIII, LXIV LXXVII XXXIX, XLV, cxv, CXXVII exx CHI LXII LXX ClI CXIX CXXVIll LVI XLIX CXXVII LXXXVI, CX LXX LX XII XXXIX, XLIII XCI LXIII XCVII CXXHI XLVI LI XLI XLI LV CXXI Cl XXXVI XCIII CXI LXI XCVI LXXIV XCIV CXVIU, CXXI, CXXII, CXXIX XXXVI, LXI LXXIX CXXXIX XXVH LXIII XCIX LXXI L, CXXIV CXIII CXXXVI eXXX, CXXXIII CXII LXXIX, LXXX CXVII XLVI XC INDEX CXLIX McMinnTille, Tenn Macon, Ga Macon County, Tenn Madison. Ark Madison Coui-t house, Va Madison Court-house, Vu Madison Station, Ala Madison County, Ky Madisonville, Ky Madisonville, La Magoffin County, Ky Magnolia Hills, Miss Malvern Hill, Va Manassas, Va Manassas Junction, Va Manassas Gap, Va Manchester, Tenn Mansfield, La Mansura, La Markham, Va JIarksville, La Mark s Mills, Auk Maria Des Cygnes, Kan Marj’land Heights, Md Marietta, Ga ivlarianna. Ark Marianna, Fla Marrowbone, Ky Marshall, Mo Marysville, Tenn Marion County, "W. A^'a Marion, Miss Marion, Va Marshfield, Mo Mason’s Neck, Va JIason’s Bridge, S. C Mattapony, Va Maysville, Ark Jlaysville, Ala Mayfield, Ky Maplesville, Ala Matagorda Bay, Tex Mazzard Prairie, Ark Martinsburg, Va Martinsburg, Mo Martin’s Creek, Ark Mathias’s Point, A’a Memphis, Tenn Memphis, Mo Jlerriweather's Ferry, Tenn . . . Mesila, N. Mex Mf.chanicsville, Va Jlechanicsville, Miss Medon Station, Tenn Jleadow Bridge, Va Meadow Bluff, \V. Va Aledalia, Miss Mcchanicsburg, Miss Medley, ’W. Va Meridian, Miss., Expedition to Aloridian, Miss Merrill’s Crossing, Mo Messenger’s Ferry, Jliss Metlcy’s Ford, Tenn Metamora, Miss Middle Creek Ford, AV. Va. . . Jliddle Creek, Ky Middleburg, A'a Middleburg, Miss Middletown, Va Middletown, Tenn Middletown, Aid Millsville, AIo Mill Creek Mills, AV. Va Mill Creek AAalley, AV. Va . . . -Mill Springs, Ky Page. LAM, LXXII, LXXXATII CXVII, CXVIll, CXXIX, CXL CXIV LXX LXXXA'II CXXXHI CIX,CXXX LV LV, LX XCVI CHI LXXIV LI, LIII, CXIII, CXAHII XXXV, LVI LXI LXII, LXXXIV LVI, Cl CII CVIII LXII ' CVIII CIV CXXVIII cxv CXI LXII exxv LXXXI LXXXIV, LXXXIX XCII XXXVI XCIX CXXXHI XLI, LXI XLU CXXXI LIII LXI LXXXV, LXXXIX XCVI CXXXVIH xcv CXVHI XXXIV, LVII, LXXVIH, CXX, CXXHI XXXV XCV XXXIV XLVIH, LIX, CV, CXXI, CXXXH LH LIV XXXVI XLIX LXXAH LXVIH CVIII XCV LXXI LX XVII XCAHI XCVII XCIX LXXXIX LXXXI XCI LIX XXXV XLI XLHI, LXXIX LXV XLAHI, LXXVIH, CXXVH . .LX VI, LXAHI, LX XVI, LXXIX, XCAH eXAH XXXV XXXVHI XCII Page. Mill Point, ■\V. Va XCII Mill Creek, Ga . CVI Mill Creek, Tenn CXXXI IMillen Grove, Ga CXXXI Millwood, Ya CXXXHI Milton, Tenn LXVIII, LXIX Milton, Fla CXXVIII Millikex's Bend, La LV, LXXVII Milford, Mo XL Milford, Va LI Milford Station, Va CIX Mingo Swamp, Mo LXVII Mine Run, Va., Operations at. XCIII Mine Creek, Kan CXXVIII Mississippi River, Miss LXVIII Mississippi City, Miss XLII Mississippi Central Railroad LVI, LXV, CXXX Missouri River, D. T LXXXIV Missionary Ridge, Tenn XCIII MitchelVs Station, Va LIV Mitchell’s Creek, Fla CXXXHI Moorefield, Va LXII, LXVI, LXXXVI, LXXXVn, XCVII, CXI, CXIX ^loore’s Mills, Mo LIII Moresburg, Tenn XCIV 3IoDroe Station, Mo XXXV Monroe County, Mo » XLVII Monroe’s Cross Roads, N. C CXXXVI Morristown, Mo XXXVII Morristown, Tenn XXXIX, XCIV, CXXVIII, CXXTX Morris Island, S. C LXXXII, LXXXV, LXXXVI Morris County, Mo CX Morgan’s Mills, Ark XCVHI Morgantown, Ky XXXIX, LXI Morgan County, Tenn XLI Morgansville, Ky LVI Morgan’s Raid in Kentucky. Indiana, and Ohio LXXXI Morganzia, La LXXXVHI Monday’s Hollow, Mo V- XXXVHI Monocacy, Md CXVI Monocacy River, Md LX Moffat’s Station, Ark CHI Mosby’s Raid in Virginia LXIX Moscow, Tenn XCI, CXHI Moscow, Ark CIII Moscow Station, Miss XCIV Mosquito Inlet, Fla XLHI Mount Zion, 3Io XL Mount Zion Church, Va CXV Mount Sterling, Ky LIH, LXIX, CXI Mount Washington, Ky LIX Mount Vernon, Ark LXXV Mount Tabor Church, N. C LXXXIV Mount Jackson, Va XCIII Mount Ivy, Miss XCIX Mount Elba, Ark Cl Mount Pleasant Landing, La CVIII Mount Clio, S. C CXXXVI Mount Pleasant, Miss CIX Mount Pleasant, Ala CXXXVIH Mount Crawford, Va CXI, CXXXVI Mount Carmel, Tenn CXXX Mobile Harbor, Ala CXIX Mossy Creek, Tex XCV Mossy Creek, Tenn XCVI Morton’s Ford, Va XCVHI Morton, Miss XCVHI Moneti’s Bluff, La CIV Morrow Creek, Ark CIV Moreauville, La CVHI Moulton, Ala CX Montgomery County, Ark CXVI Montgomery and West Point Railroad, Ga CXVII Montgomery, Ala CXXXIX Moreau Bottom, Mo ('XXVI Monteith Swamp, Ga C'XXXH CL INDEX Page. Mocassin Gap, Va CXXXIII Mountain Grove, Mo XLII Mountain Store, Mo LH Monterey, Ky XLIX Monterey, Va XLV ]\ronterej% Tenn XLVI Monterey Gap, Md LXXXI Slontavallo, ]\Io XLV, LIII Montavallo, Ala CXXXVIII Morning Sun, Tenn LI Mobile, Ala CXXXVII Monticello, Ky LXXIV, LXXVII Monticello, Ark Cl Munson's Hill, Va XXXVI, XXXVII Munford's Station, Ala CXL Munfordsville, Ky XL, LVII, LIX Murfreesboro’, Tenn LI, LXV, LXIX, LXXVII, LXXIX, CXXIII, CXXXI, CXXXII, CXXXIII Murfreesboro’ R()ad, Tenn LXXXVIII Muldraugh’s Hill, Ky LXV Muddy Run, Va XCII Mud Springs, 1. T CXXXV Mussel Shoals, Ala CXXVIII Mulberry Gap, Tenn XCIX Mustang Island, Tex XCIII Myerstown, Va CXXIX Xansemond, Va *. LXXI Nansemond River, Va LXXIV Namozin Church, Va CXXXVIII Karrows, Ga CXXVI Nashville, Tenn XLII, LII, LX, LXII, CIX, CXXXI, CXXXII Nashville and Chattanooga Railroad, Tenn CXX, CXXII Natches, Miss LXXXIV, XCII, XCIV Natchitoches, La Cl, CIV Natural Bridge, Fla CXXXVI Nauvoo, Ala CXXXIV Nelson’s Farm, Va L Neosho, Mo XLVI, XLVIII, LXXXVIII Neuse River, N. C CXXXIX Newark, Mo LIII Newnan, Ga CXVIII New Berne, N. C XLiil, XLVI. XLVII, LXII, LXVHI, LXIX, XCVII, C New Market, Va CVIII, CXVIII, CXXVI New Market Bridge, Va XL New Market Cross Roads, Va L New Market Heights, Va CXXV, CXXVI Newport News, Va XXXIV, XL, XLII Newport Barracks, N. C XCVII Newtonia, Mo LVII, CXXVIII Newton, La LXXXVIII Newtown, Va XLVII, CXXIX New Creek, W. Va XXXIV, CXIX, CXXX New Creek Valley, MV. Va XCVII New Albany, Miss LXXII, LXXXVIII New Baltimore, Va LXII New Bridge, Va XLVII New Hope, Ky LI New Hope Church, Ga CX New Lisbon, Ohio LXXXIV New Madrid, Mo. . . . XLII, XLIII, LXXXV New Madrid Bend, Tenn XCl New Orleans, La XLVI New River Bridge, Va CVII New Ulm, Minn LV Nickajack Trace, Ga CIV Nickajack Creek, Ga CXV Nineveh, Va CXXIX Niobrara, Neb XCIV Nolansville, Md LVII Nolansville, Tenn LXV, LX^VTII Noonday Creek, Ga C X III Norfolk, Va XLVI Northeast River, N. C LXVI Northport, Ala NORTH Anna River, Va North Edisto River, S. C North Fork, Va North Mountain, Va North Missouri Railroad North River, MV. Va North Shenandoah, Va Nose’s Creek, Ga Nottaway Creek, Va Nottaway Court-house, Va . . Nueces River, Tex Oak Grove, Va Oakland, Miss Obion River, Tenn Occoquan, Va Occoquan Creek, Va Occoquan Bridge, Va Ocean Pond, Fla Oconee River, Ga Offett’s Knob, Mo Ogeechec River, Ga Okalona, Jliss Okaloua, Ark . . : Oldtown, Md Old Church, Va Old Fort Wayne, Ark Old Oaks, La Old River, La Old River Lake, Ark Olive Branch, La Olive Hill, Ky Olustee, Fla Oostenaula, Ga Opelousas, La Opequan, Va Orangeburg, S. C Orange Court-house, Va Orchards, Va Orchard Knob, Tenn Oregon Mountains Orleans, Ind Osage, Mo Osceola, Mo Osceola, Ark Otter Creek, Va Overall’s Creek, Tenn Overton’s Hill, Tenn Owens Valley, Tenn Owens River, Cal Owen County, Ky Owensburg, Ky Oweusborough, Ky Oxford Hill, Miss Oxford Bend, Ark Ox Hill, Va Ozark, Mo Paint Rock Railroad Bridge Paintsville, Ky Palo Alto, Miss Palmyra, Mo Palmyra, Tenn Palmetto Ranch, Tex Paducah, Ky Pamunkey River, Va Panther Creek, Mo Panther Springs, Tenn Panther Gap, W. Va Papinsville, Mo Paris, Ky Paris, Tenn Parkersville, Mo Parker's Cross Roads, Tenn Pasquotank, Mo Page. CXXXVIII LU, CVII, CIX CXXXV CXXXVI CXV CXXV CXV CXXVI .. CXI, exm, CXXV CVII CXIV LIV XLIX LXIII LIV XLII, LXV XXXIX XLI XCIX CXXX CIV CXXXI XCIX CII CXIX CX, CXII LXI CIX LXVII, CIX CXI CXXXVI LIX XCIX CVIII xc CXXIII CXXXV LII, LIII XLIX XCIII XCVII LXXVII! LXI XXXVII, XLVII CII, CXIX CXIII CXXXI CXXXII LXVIII XLV XLIX LVIII exxu CXXI LXI LVI ...LUI, LXin, CXVI XLVI XLI, XCIII LXXII XXXIX XCII CXL Cl CX LIV C CXI XXXVII LIII, LXIX, LXXXIV XLII, LX XXVII XXXV LXV LXXXV INDEX. GDI Page. Pass Chiistian, Sliss XLIII Pattacassey Creek, N. C LXXXIV Patton, Mo Patterson, Mo LXXII Pattersonville, La LXX Patterson Creek, Va XXXIV, XCA II Pawnee Reservation LXXIX Pawnee Porks, Kan CXXX Peach Ouchaud. Va L PEACH Thee Cheek, Ga CXVII Pea Ridge, Auk XLII Pea Vine Creek, Ga XCIV Peehacho Pass, D. T XLV Pembiscott Bayou, Ark Cil Pensacola, Pla XXXIX, CII Peralto, N. Mex XLV Perry County, Ky LXII Pekuyville, Ky LX Perryville, Ark LX XXV Petersburgh, W. Va XXXVII, XCVI Peteusuuug, Va LIII, CXII, cxiii, cxv, cxviii, cxix, cxxn, cxxxi, cxxxvn, cxxxviii Petersburg, Tenn LXVIll Petit Jean, Ark CXVI Philadelphia, Tenn XC, XCI Philip's Creek, Miss XLVII I’hillippi, W. Va XXXIV Philouiont, Va LXI PIEDMONT, Va CXI Piedmont Station, Va LXXV Pierce's Point, Fla CXXVII Pierson's Farm, Va CXIII Pike County, Ky , XXXIX Piketown, Ky XXXIX Pike Creek, Ky ■ CVIII Pikeville, Ky LX XI Pikesville, Ark CXIV Pilot Knob, Mo CXXVIII Pineknej" Island, S. C LV Pine Blull', Ark XCI, XCVI, CXIII, CXV, CXVIII, CXXVI Pine Bluff, Tenn CXXI Pine Barren Creek, Ala CXXXIII, CXXXVII Pine Knob, Ga CXIII Pine Mountain, Ga CXII Pinevilie, Mo - LXXXV Piney Factory, Tenn XCI Piney Woods, La CII Pinos Altos, Ariz LXVII Pittman's Ferry, Ark LII Pittman's Ferry, Mo LXI Pittsburg Landing, Tenn XLII, XLV Plaquemine Bayou, La LXVII Plaquemine, La LXXI.X, CXIX Plain Stores, La Plattsbmg, Mo Platte City, Mo Pleasant Hill, Mo Pleasant Hill, La Pleasant Hill Lauding, La Pleasant Grove, La Pleasant Valley, Md Plymouth, X. C Plantersville POCATALIGO, S. C Pocahontas County, AV. Va I’oint Lookout, A'a Point of Rocks, Md Point Lick, Ky Point Pleasant, AV. Va Point Pleasant, La Point AVashington, Fla Poison Springs, Ark Polk's Plantation, Ark POPLAIl Si’ULNGS CHUKCH, VA LXXA'I, (TI XXXIX CXV LI, CX CHI CHI CH CXV ...-LATI,CIH, CXXIX CXXXATH XLVII, LXI, CXXXIV XCH CVIH ....XXXVI, CXI, CXV LXI LXX CXIV XCA'HI CHI LXXVI CXXV Pollocksville, N. C Polk County, AIo Pond County, Ky Pond Spring, Ala Pontotoc, Miss Ponchatoula, La Poolesville, Md Pope's Campaign in A'irginia . Port Royal, S. C Poet Republic, Va Port Gibson, Miss Poet Hudson, La Port Hudson, La Port Hudson Plains, La Port AValthal, Va Poole’s Station, Ga Potosi, Mo Pound Gap, A’a Pound Gap, Tenn Pound Gap, Ky Powel’s River Bridge, Tenn.. Powder Springs, Ga Powhattan, A'a Prairie D’Ann, Ark Prairie Station, Mo Prairie Station, Miss PuAiuiE Grove, Ark Preble's Farm, A'a Prentis, Miss Price’s Invasion of Missouri . . Princeton, AA’. Va Princeton, Ky Princeton, Ark Prince's Place, Mo Pritchard's Jlill, Md Pueblo Colorado, N. M Pulaski, Ala Pulaski, Tenu Pulaski, Ga Pumpkin A’ine Creek, Ga Putnam's Ferry, Mo Quaker Bridge, N. C Quaker Road, A’a Qualltown, N. C Quicksand Creek, Ky Raccoon Ford, Va Raccoon Ford, Ala Raeeland, La Randolph County, Mo Rapidan, Va Rapidan Station, A’a Rapidan Railroad Bridge, Va. Rappahannock, Va Rappahannock River, A’a Rappahannock Bridge, Va ... Rappahannock Crossing, A’a. Rappahannock Station, Va . . . Rawle's Mills, N. C Ray County, Mo Raymond, Miss Raytown, Mo Ready ville, Tenn Ream’s Station, A’a Rectortown, Va Red Bone, Miss Bed Bono Church, Mo Red Clay, Ga Red HilJ, Ala Red House, AV. Va Red Mound, Tenn Red Oak, Ga Red River, La Redwood Creek, Cal Redwood, Miss Page. XLV, LXVI XLIII CVIH CXXXHl CXVI LA’IH, LXX, LXXV LA TI LAT XXXIX, XL XLA’HI LXXIA’, XCV, eXA’, CXVI LXIX ,LXXVH, LXXVHI, LXXXH, CH LXXA’I CVI CXXXI XXXVI, XXXVHI CXXV XLIII, LXXXI CHI XCIX CXHI,CXXV CXXXIV CHI LXVIII XCIX : LXIV CXXV LIX CXXIV XLA’H, CVI CXII XCIV, CIH, CXXA’HI CXXVI XXXVH LXXXV LXXXHI LXXXIX, CXXV, CXXXHl CVIH CX XLIII LXXXI CA’II XCA’HI CII LXXXVH CXXVIII XLIX XXXIX LXXXIX, XC,C LXXIV, LXXXVH LI LXXXIX, Cl LA’, LXXHI LXII, XCI XC LXXXIV, XCH LXII XXXVHI LXXV, XCVII XLIX LAT CXIV, CXVI, CXXI XCV CIV LXXXVHI CV CXXXIV XXXV LXV CXXI LXVIII, CIV, CV LXXXH LV CLII I N 1) E X Page. I’cod’a Mountains, Ark ' P>ee(ly Creek, W. Ya Kcnick, JIo Iterock, Ariz P,ESACA, GA Itcynold's I’lantation Khea's Mills, Ark P.hcatown, Tenn Pacliiield, Mo Pdichland, Ark Kicliland, Tcnn llioli Mountain, 'SV. Ya ItiCiniOKD. KY lliohmond. La IIICII.MONI), Ya Richmond & Petersburg Railroad, Ya Rickett’s Hill, Tenn Riddle’s Shop, Ya Rienzi, Miss Ringgold, Ga Riple}’, Tenn Ripley, Miss River’s Bridge, S. C Robertson's Run, Ya Roan’s Tan Yard Roanoke Island, N. C Roanoke River, N. C Roach’s Plantation, Miss - Rocheport, Mo Rockford, Tenn Rockingham, N. C Rockport, Mo Rockville, Md Rocky Creek Church, Ga Rocky Crossing, Miss Rocky Face Ridge, Ga Rocky Gap, Ky Rocky Gap, Ya Rocky House, AY. Ya Rocky Mount Raid, N. C Rodgcrsville, Ala Rodgersville, Tenn Rodney, Miss Rogersville, Tenn Rolla, Mo Rolling Fork, Miss Rolling Prairie, Ark Rolling Prairie, Mo Rome, Ga Romney, W. Ya Rood’s Hill, Va Rosecrans’ Campaign in Tennessee Roseville, Ark Rousseau’s Raid in Alabama and Georgia Rousseau's Pursuit of lYheeler, Tenn Round Away Bayou, La Round Hill, Ark Round Hill, Tenn Rover, Tenn Rowanty Creek, Ya Rowlett’s Station, Ky Running Yicksburg Batteries Rural Hills, Tenn Rush Creek, I. T Russel’s House, Miss Russellville, Tenn Russellville, Ky Rutherford’s Creek, Tenn Sabine Pass, Tex Sabine Pass, La Sabine Cross Roads, La Sacramento, Ky Sacramento Mountain, Va Salem, N. C LXHI XLYI XXXIX CXXXVII cvm, cxxvii exxx LXII LXXXIX LXXVI cv CXXIV XXXV LYI, LXXXIV LXX, LXXYHI C, evil. CXXVIII, CXXXYHI evil LYII CXII LV LXXXVI, XCIV LXVI XCIY, CXI, CXII, CXVI cxxxv LXXXIX XLI XLI CV Cl LXXVII XCII CXXXVI CXXIV LXXXVII CXXXI LXXIX C, CVI LXXVII LXXXV XCVIII LXXXIH XLYI CXXI XCV, C XCII XXXV, CXIX CXXIX XCYI XCVII LX XIII, CVIII, CIX . . . -XXXIV, XXXYHI, LXYIII evin, exxx LXXIX XCII, CII CXYI CXXII LXX LI LYI LXYII CXXXV XL LXXI LXIH CXXXV XLYI LI LIII, LIX LXIX, CXXXHI LXXII LXXXVI CII XL CXXI CXXXYHI .Salem, Miss .Salem, Va Salem, Mo Salem, Ark .Salem Cemetery, Tenn Salem Pike, Tenn Salem Church, Va .Salkahatchie, S. C Salisbury, Tenn Salisbury, N. C Saline County, Mo Saline River, Ark Salt Lick, Va Saltville, Va Salyersville, Ky Sailor's Creek, A^a Saint Charles River, Ark Samaria Church, Va Sam Gaty, Massacre on Steamer. San Carlos River, Cal .Sand Creek, I. T Sand Mountain, Ala Sandersville, Ga .Sangster’s Station, Va Santa I’e, N. M Santa Fe, Mo Santa Rosa. Fla Saratoga, Ky Sartoria, Miss Saunders, Fla Saulsbury, Miss Savage Station, Va Savannah, Tenn Savannah, Ga., Siege of ScatterviUe, Ark Scott’s Mills Road, Tenn Scott’s Farm, Ark Scottsboro’, Ala .Scottstdlle, Ala Scrougesville, Tenn Scully ville, I. T Seabrook’s Point, S. C Searcy, Ark .Searcy Landing, Ark Scarytown, AV. Va Secessionville, S. C Sedalia, Mo Selma, Ala Senatobia, Miss Seneca, Md Seneca Station, I. T Seven Days’ Retreat, Va Seven Pines, A'^a Seviersville, Tenn Shady .Springs, Va Shanghai, Mo Shannon Hill, Va Sharjisburg, Md Shawnee Mound, Mo Shawnee Town, Kan .Shelby Depot, Tenn Shelby County, Ky Shelbjwille, Tenn Shelbjwllle Pike, Tenn Shelbina, Mo Shelburne, Mo Shenandoah, A’a Shenandoah River, Va Shepherdstown, A’a Sheppardstown, A’a Shepherdsville, Ky .Sheridan’s Cavahy Raid, Va . . .Sherwood, Mo Siiii.oH, Tenn Page. LXXXIX LXII.CXIH XXXIX XLHI Lxrv LXIX CXI cxxxv LI V, XCIV CXXXIX LXXXIV CV xc eXXA’, CXXXII, CXXXHI XCIV CXXXIX CXIV CXIH, CXIV LXX CX CXXXII LXXHI exxx XCV XLHI LII XXXVHI XXXVHI LXXVII CIX cxv L XLV CXXXII LI XCVII XCVIII CXXXIV CXXXVHI LXIH cm XLVIII CXI, cxv, CXXIII XLVI XXXIV XLIX, LXXXIH XXXIX, CXXA'II CXXXVHI LXXA’I Lxxvm LXXXVH L XLVIII XCVII LVI, LXXXIH XXXVII, XXXVHI LXXIV LVIII XL LXXVII LXI XL LXXX LXXVH, LXXIX, LXXXIX XXXVII LVIII CXXXVI CXVH LIX, CXXI LVUI, LXXXIH LIX CVH, CXXXVI LXXV XLV INDEX CLIII • Page. Ship's Gap, Ga CXXVII Shirley's Ford, JIo LVIII Shoal Creek, Ala CXXIX Sibley's Landing, JIo LX, LXX Silver Creek, Mo XLI Silver Lake, Fla XCIX Silver Run, N. C CXXXVI Simmsport, La CIX Simpsonville, Ky CXXXIV Sinking Creek, Va LXIII Sipsey Swamp, Ala CXXXIX Six Mile House, Va CXX Six Mile Creek, Ala CXXXVIII Skeet, N. C LXVIH Slatersville, Va XLVI Slaughter Mountain, Va LFV Slaughterville, Ky LVII Smithfield, Va LXVII, LXXXVII, XCVII, CUI, CXXI, CXXII Smithfield, Ky CXXXIV Smithshurg, Md LXXXI Smith's Farm, N. C CXXXVII Smith's Raid in Tennessee XCVIII, CXV Smith's Station, I. T CVII Smithville, Ark XLIX Smoky Hill, C. T CVIII Smoky Hill Crossing, Kan CXX Smyrna, Ga CXV Snaggy Point, La CV Snake Creek Gap, Ga CVII, CXXVII Snia Hills, Mo CIV, CIX Snicker's Gap, Va LXI, CXVI Snicker's Gap Pike, Va CXXI Snicker's Ferry, Va LXIII, CXVII Snow Hill, Tenn LXX Snyder's Bluff, Miss LXXIII Snydersville, Miss Cl Solomon’s Gap, Md CXVI Somerset, Ky XLI, LXX Somendlle Heights, Va XLVI Somerville, Tenn LXX Sounding Gap, Tenn XLIII South Anna, Va LXXX, C, CVII, CXXXVI South Branch of Watonwan, Minn LXXI South Edisto River, S. C CXXXV South Fork, Potomac, Va LXII South Fork, Oreg CXXXIX South Mills, N. C XLVI SOUTH Mountain', md LVIII South Qua}', Va LXXI South Quay Bridge, Va LXXFV Southside Railroad, Va CXXVni South Tunnel, Tenn CXXVI South Union, Ky LXXV Southwest Mountain, Va LIV Southwest Creek, N. C LXIV Spanish Fort, Ala CXXXVn Spanish Fort Canon, U. T LXXI S'parta, Tenn LIH, LXXXV, XCIII SpeiTj-ville, Va LI Spoon-ville, Ark CII Sporting Hill, Pa LXXX SrOTTSYLVANIA COURT HOUSE, VA LXXIII, CVI Springfield, Mo XXXVUI, XXXIX, LXVI Springfield, W. Va XCVII Springfield Landing, La LXXXI Spring Hill, Tenn LXIX, CXXX Spring River, Ark XLHI, XCVIII Spring River, Mo LVIII, LXVUI Stanardsville, Va C State Creek, Kan LXXVIII Statesboro’, Ga CXXXI .Stamford, Ky Lx Stahcl's Reconnoissance, Va LXIII .Staunton Bridge, Va CXIV 20 * Page. Stanton Road, Va XLVUI St. Augustine, Fla XCV St. Catharine's Creek, Miss LXXXIV St. Franeois River, Mo LXXIII St. George’s Creek, Ohio LXXXIII St. Charles, Ark XLIX St. Francis County, Mo LXXI St. John’s River, Fla CIX St. Mary's River, Fla XCVIII St. Mary's Trestle. Fla CXVII St. Louis, Mo XXXIV St. Vrain’s Old Fort, N. Mex CXXX Steele's Bayou, Miss LXIX Sterling’s Farm, La LXXXVHI Sterling’s Plantation, La LXXXVII Steamer Empress, Miss CXIX Stevensburg, Va XCII, C Stevens’ Gap, Ga LXXXVI Stevenson, Ala LVI Stevenson’s Depot, Va CXVII Stewart’s Plantation, Ark L Stewart’s Creek, Tenn LXV, LXVI Stone’s Farm, Ark CII Stone’s Ferry, Ala CXVI Stone’s River, Tenn LXVI Stony Lake, D. T LXXXIV Stony Creek, Va CXIV Stony Creek Station, Va CVI, CXXVI, CXXX Stono Inlet, S. C LXXI, XCV Stockton, Mo LIV Stockade at Stone’s River, Tenn LXXXVHI Stoneman’s Raid in Va LXXIII Stoneman’s Raid to Macon, Ga CXVII Stoneman’s Raid in Tenn. and Va CXXXII Stoneman’s Raid in Southwest Va. and N. C-. CXXXVII Strasburg, Va XLIH, XL VIII, CXX,'CXXVI, CXXVII Strasburg Road, Va LXVIll, LXXII Strawberry Plains, Tenn XCVI Strawberry Plains, Va CXX Streight’s Raid in Georgia and Alabama LXXIII Sturgeon, Mo LIX Sugar Creek, Mo XLI, XLII Sugar Creek, Tenn LXXXIX, CXXXIII Sugar Loaf Mountain, Md LVII Sugar Loaf Hill, N. C CXXXIV Sugar Loaf Battery, N. C - CXXXV Sugar Valley, Ga CVIII Sulphur Braneh Trestle, Ala CXXIV Sulphirr Springs, Va LV Sulphur Springs Bridge, Va CXIX Suffolk, Va LXV, LXXI, LXXV, C Summerville, W. Va XXXVI, LXVII Summerville, Miss LXIII Summerville, Tenn XCV Summit Point, Va CXXI Sumtervillo, S. C CXXXVII, CXXXIX Sunshine Church, Ga CXIX Surrender of Genl. Lee CXXXIX Surrender of Genl. Johnston CXL .Surrender of Genl. Taylor CXL Surrender of Genl. Sam. Jones CXL Surrender of Genl. Jeff. Thompson CXL Surrender of Genl. Kirby Smith CXL Supply Train, Tenn XCI Sutton, Va LIX Suwano Gap, N. C CXL Swallow's Bluff, Tenn LXXXVHI Swan Lake, Ark • CIV .Sweden’s Cove, Tenn XLVHI Sweetwater, Tenn XCI Sweetwater Creek, Ga CXXV .Swift Creek, Va CVII .Swift Creek, .S. C CXXXIX Swift Creek Bridge, N. C L CLIV INDEX. Sycamore Church, Va Sykestown, Mo Sylamore, Ark Sylvan Grove, Ga Taberville, Mo Taben’ille, Ark Tah-Kah-o-Kuty, D. T Tahliquah, I. T Talladega, Ala Talbott's Ferry, Ark Talbot's Station, Tenn Tallahatchie, Fla Tallahatchie, Miss Tallahassee, Fla Tallapoosa River, Ala Tanner’s Bridge, Ga Tar River, N. C Taylor's Ford, Ky Taylor’s Ridge. Ga Taylor’s Hole Creek Taylorsville, Va Tazewell, Tenn Tebb's Bend, Ky Telford, Tenn Ten Islands, Ala Ten Miles from Columbus, Ky Tennessee River, Tenn Terrapin Creek, Ala Terre Noire Creek, Ark Terrisville, Tenn Texas County, Mo The Island, Mo Thibodeaux, La Thibodeauxville, La Thomas Station, Ga Thompson Cove, Tenn Thompson's Hill, Miss Thompson's Station, Tenn Thornburg, Va Thornhill, Ala Thoroughfare Gap, Va Tiekfaw River, Miss Tillaflnney River, S. C Tiiton, Tenn Tilton, Ga Tishamingo County, Miss Tobosofkee, Ga Todd's Tavern, Va Tolopotomy, Va Tolopotomy Creek, Va Tompkinsville, Ky Tom’s Brook, Va Toon’s Station, Tenn Town Creek, Ala Town Creek, N. C Township, Fla Tracy City, Tenn Trantner’s Creek, N. C Trenton, Tenn Trenton, N. C Trenton Bridge, N. C Trevillian Station, Va 'Trinity, Ala Trinity River, Cal Trion, Ala Triplett's Bridge, Ky Truine, Tenn Try Mountain, Ky Tullahoma, Tenn Tuniea County, Miss Tunnel Hill, Ga Tunnel Hill, Miss Tunstall Station, Va Tupelo, Miss Page. LIII, CXXIII XLII XLII CXXX LIII LIV CXVIII LXX CXL XLVI XCV XLIX LXXIX, LXXXIX, CXIX CXL CXVI CVIII LXXXIII XXXIX XCIV.CXXVII CXXXVII C Lrv,xcvi LXXXI LXXXVI CXVI CXXXIV CXXI CXXVIll CII XCVI Lxni, LXXXVI LXX LXXIX LXI CXXX, CXXXI Lxxxvm LXXIV LXIX LIII CXXXIV LX, LXII LXXIV CXXXI CVIII CXXVII XCI CIV CVI cx cx LI, LXXII CXXVI LVI Lxxm cxxxv LXVII XCVI XLVIII LIV, LXV LXIV XLVI CXII LII XCII CXXXVHI LXXVIII LXXVIII XXXIX LXXIX, LXXX, XCI Lin XCVII, C, CVI XCIX XLIX, LXXIV, C LXXIV, CXV, CXVI Page. Turkey Bend, Va L Turkey Island Bridge, Va LII Turman’s Ferry, Ky XCVI Turnback Creek, Mo XLVI Turner’s and Crampton’s Gaps, Md LVIII Tuscumbia, Ala LXVIII, LXXII, LXXIII, XCI Tuscumbia Creek, Miss XLVII Tuscaloosa, Ala CXXXIX Two Hills, Bad Lands, D. T CXIX Union, Va LXI Union City, Tenn XLIII, LXXXII, XCIII Union City, Ky Cl Union Church, Va XLVIII Union Church, Miss LXXIII Union Mills, Mo LV Unionville, Tenn LXIX Union Station, Tenn CXXIX University Place, Tenn LXXXI Upper Missouri River, Ark LX Upperville. Va LXI, LXXIX, LXXXVIII Upton Hill, Ky XXXVIU Utoy Creek, Ga XLIX Vache Grasse, Ark CXXIV Valverde, N. Mex XLII Van Buren, Ark LXV, CXIX Vamell’s Station, Ga CVII Vaughn, Miss CVII Vaughn Road, Va CXXVIU, CXXXV Vaught’s Hill, Tenn LXIX Vera Cruz, Ark CXXIX Vermillion Bayou, La LXXXIX Vernon, Ind LXXXII Verona, Miss CXXXIII Vicksburg, Miss XLIX, LXV, LXVm, LXXXVI, LXXIX, LXXX, LXXXV, XCVH, XCVHI, CXV Vidalia, La LXXXVH, XCVIII, CXVII Vienna, Va XXXIV, XXXIX, LVU Village Creek, Ark XLIX, L Vincent’s Cross Roads, Miss XCI Vinegar Hill, S. C LXXXV Vining Station, Ga CXV Volusia County, Fla CXXXV Wachita, Indian Agency, Tex LXVTI Wadesburg, Mo XL Waddel's Farm, Ark XLIX, L Waldron, Ark LXXXVH, LXXXIX, XCV, XCVII Wallace's Ferry, Ark CXVH Wall Bridge, Va CV Walkersville, Mo XLV Walker’s Ford, W. Va XCIV Walkertown, Va C Walthal, Va CXIII Wapping Heights, Va LXXXIV Wardensville, Va XLVII Warm Springs, N. Mex LXXIX Warm Springs, N. C XCIH Warrenburg, Mo XLHI, XLIX Warrenton Junction, Va LIX, LXXIV, LXXV WaiTenton Springs, Va LXXXIX Warsaw, Mo XXXVIU, LXXXIX Wartrace, Tenn LXXXVIII Washington, N. C XLVHI, LVII, LXX, XCI Washington, D. C CXVI Watauga River, Tenn CXXV Waterford, Miss LXIIl Waterford, Va LXXXIV Waterloo Bridge, Va Water Proof, La XCIII, XCIX, CIV Water Valley, Miss LXUI Waugh's Farm, Ark XCIX Wauhatchie, Tenn ^^I Wautauga River, Tenn XXXIX Wautauga Bridge, Tenn LXV, CIV Waverly, Tenn LXI, LXXl INDEX CLV Page. Wayne Countj', W. Va XCVIII WajTio Court house, W. Va XXXVI Wajniesville, Mo LXXXV Wajaiesboro’, Va CXXV, CXXXVI WajTiesboro’, Ga CXXX, CXXXI Weaver’s Store, Ky LXXIII Weber's Falls, I. T LXXXVI Welaka, Fla CIX Weldox llAiLitOAD, Va CVI, CVII, CXIV, CXX, CXXV, CXXXI Wentzville, Mo XXXV Western North Carolina, Expedition into CXXXII Westminster, Md LXXX Westport, Mo LXXVm, CXXVHT Weston, W. Va LVI West Branch, Va LXXI Wet Glaze, Mo. XXXVIII West Liberty, Ky XXXVIII West Point, Va XLVI West Point, Ark LXXXV, CXIII, CXVUI West Point, Miss XCIX West Point, Ga CXXXIX West Virginia, AveriU’s Raid LXXXV Weyer's Cave, Va CXXIV Whistler’s Station, Ala CXXXIX Whitemarsh, Ga XLV White’s Bridge, Va CVII White’s Ford, Va LXXXVII Whiteside, Fla CXVIII Whittaker's Mills, Va LXXI White County, Ark XCVIII White Count}', Tenn XCIX Whitehall, N. C LXIV White House, Va CXIII White Oak Swamp, Va L White Oak Swamp Bridge, Va LIU, CXII White Oak Bridge, Ky LV White Oak Road, Va CXXXVIII White Post, W. Va - CXH, CXIX. CXXXI White River, Ark XLIX, LXXXV, CXIV, CXXVIII White Stone Hill, D. T LXXXVI White Sulphur Springs, Va LXIII, LXXXV, LXXXIX White Water, Mo LXXII Wier Bottom Church, Va CXIII Wilcox’s Bridge, N. C CXXXVI Wild Cat. Ky XXXVIII WiLDERXESS, Va CVI Wiliston, S. C CXXXV Willis’ Church, Va L Williamsburg, Va XLVI, LI, LVII, LXVII, LXX, LXXI Williamsburg, Ky LXI Williamsburg Road, Va XLIX Williams’ Bridge, La XLIX Page. Williams’ Farm, Va CXIV Williamsport, Tenn LIV Williamsport, Md LIX, LXXXI Williamsport, W. Va XCVII Williamston, N. C LXII Willicomack, Va CXXXVIII Willmarsh Island, S. C XCIX Willow Creek, Cal XCITI Wilmington Island, Ga XLV Wilmington, N. C CXXXVI Wilson’s Creek, Mo XXXVI Wilson’s Creek, Ky LXXVIII Wilson’s Farm, La CII Wilson’s Landing, Va CXII Wilson’s Wharf Landing, Va CIX Wilson’s Raid on Weldon R. R., Va CXIV Wilson’s Raid in Alabama and Georgia CXXXVII Winchester, VA.XLIII,XLVn,LXXVI,LXXVin,CXVn,CXX,CXXllI Wireman’s Shoals, Ky LXIII Wirt Court House, W. Va XXXIX Wise’s Fork, N. C CXXXVI Wolf Creek Bridge, Miss LIX Wolf River, Tenn CII Wolf River, Miss LXV Wolf River Bridge, Miss XCIV Woodbury, Ky XXXIX Woodbury, Tenn LXVII, LXX Wood Lake, Minn LIX Wood’s Fork, Mo LXVI Woodson ville, Ky XL Woodstock, Va CXXIV, CXXVI Wood ville, Tenn LXI Woodville, Miss CXXVI Wonnley’s Gap, Va CXXII Worthington, W. Va XXXVI Wyatt’s, Miss LXXXIX, XCVIII Wyerman’s Mills, Tenn XCIX Wyoming Court house, W. Va LIV Wytheville, Va LXXXHI, CVII, CXXXHI, CXXXVHI Yates’ Ford, Ky LVI Yazoo Pass, Miss LXVIII Yazoo City, Miss LXXXII, C, CV, CXXXI Yazoo River, Expedition up. Miss XCVII Yellow Bayou, La CIX Yellow Medicine, Minn LIX Yellow Tavern, Va CVII, CXXV Yemassee, S. C LXI Yorktown, Va XLin, XLV, XLVI Young's Cross Roads, N. C Lll Zagonyi’s Charge XXXVIII Zollicoffer, Tenn LXXXVIII Zuni, Va LXIV ON SPECIAL WOUNDS AND INJURIES. CtlAPTKIl I WOUNDS AND INJURIES OF THE HEAD. The wounds and injuries of the head will be described in three categories : incised and punctured wounds, comprising, mainly, the sabre-cuts, bayonet-stabs, and sword-thrusts ; miscellaneous injuries, resulting from falls, blows from blunt weapons, and various acci- dents ; and lastly, and principally, gunshot wounds. Section I. INCISED AND PUNOTUEED WOUNDS. Tlie cases of incised and punctured wounds of the head are subdivided into those in which the lesions involved the integuments only, and those in which the bones of the skull, and, in some instances, its contents, were injured. Brief abstracts, arranged in alphabetical order, are given of all the examples of incised and punctured wounds of the head, recorded in the Surgeon General’s Office. The names of the wounded of the United States Armies are printed in small capitals ; those of the Confederate Armies arc distin- guished by italics. Incised Scalp Wounds. — The returns furnish memoranda of two hundred and eighty-two cases of incised wounds of the head which appeared to involve the integuments only, as follows : 2 WOUNDS AND INJURIES OF THE HEAD. Adams, Oscak H., Assistant Surgeon 8tli New York Cavalry, aged 32 years. Wounded at Lacey’s Springs, Virginia, December 21st, 1864, ny a sabre-cut five inches in length over the right parietal and temporal legions. Admitted to Officers’ General Hospital, Annapolis, Maryland, January 4th, 1865. On leave January 18th. Re-admitted February 5th. Suffers from frequent attacks of vertigo, incipient amaurosis, loss of memory, partial paralysis of right eyelid, and imperfect vision. Resigned February 17th, 1865. , Adams, J. F., Private, Co. I, 21st Virginia Cavalry. Incised wound of the scalp. Opequan, Virginia, September 19th, 1864. Admitted to Sheridan Field Hospital, September 24th. Recovered and transferred for exchange, November 15th, 1864. Agee, John, Private, Co. G, 21st Virginia Cavalry. Incised wound of the scalp. Newtown, Virginia, November 9th, 1864. Captured and admitted to Sheridan Field Hospital, November 14th. Transferred for exchange November 15th, 1864, well. Akins, Charles, Sergeant, Co. A, 3d New Jersey Cavalry, aged 24 years, received at Appomattox Court House, Vir- ginia, April 8th, 1865, a slight cut over the forehead, implicating the scalp only, and a gunshot wound, for which the middle toes of the right foot were amputated. Admitted to Jarvis Hospital, Baltunore, Maryland, on April 22d, and transferred, July 24th, to Hicks Hospital, from whence he was transferred, well, September 6th, 1865, to New York, to be mustered out of service. Anderson, Ransom A. D., Private, Co. B, 6th U. S. Colored Artillery, aged 22 years. Three sabre-cuts of the scalp and one of the right hand. Fort Pillow, Tennessee, Apiil 12th, 1864. Admitted to Mound City Hospital, Illinois, April 17th. Returned to duty June 21st, 1864. {See Report No. 55, House of Representatives, 1st Session 'iSth Congress.) Austin, George W., Private, Co. B, 1st Vermont Cavalry, aged 23 years. Incised wound of scalp over left parietal region. Wilderness, May 5th, 1864. Admitted to Douglas Hospital, Washington, D. C., May 11th. Transferred May 14th to Mower Hospital, Philadelphia. Returned to duty September 4th, 1864. Bailey, Simon Z., Private, Co. B, 18th Pennsylvania Cavalry, aged 28 years, received a sabre-cut of the scalp at Han- over, Pennsylvania, June 30th, 1863. Admitted to Cuyler Hospital, Germantown, Pennsylvania, October 2d, 1863. Trans- ferred to Christian Street Hospital, Philadelphia, December 21st. Deserted February 17th, 1864. Baker, Ezekiel, Private, Co. K, 4th Pennsylvania Cavalry. Sabre-cut of the scalp. Middleburg, Virginia, June 19th, 1863. Admitted to Emory Hospital, Wasluugton, June 21st. Returned to duty August 13th, 1863. Beals, D. A., Private, Co. A, 1st Michigan Cavalry, aged 23 years. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to Satterlee Hospital, Philadelphia, July 10th. Returned to duty October 23d, 1863. Bates, George L., Piivate, Co. B, 1st Vermont Cavalry. Sabre-cut of the head. Mount Jackson, Virginia, October 7th, 1864. Admitted to hospital at Brattleboro, Vermont, April 2d, 1865. Returned to duty June 23d, 1865. Baugh, J. F., Private, Co. A, 1st Georgia Cavalry. Sabre-cut of the head. Admitted to hospital, Petersburg, Virginia, November 18th, 1862. Returned to duty December 2d, 1862. Bcckner, Abner, Private, Co. G, 21st Viiginia Cavalry, aged 45 years. Sabre-cut of the left parietal region. Front Royal, Virginia, November 12th, 1864. Admitted to West’s Buildings Hospital, Baltimore, Maryland, November 16th. Trans- ferred to Fort McHenry, January 8th, 1865, and thence to Point Lookout, and exchanged June 28th, 1865. Belcher, A. F., Lieutenant, 4th Massachusetts Cavalry, received a sabre-cut an inch and a half long over the left super- ciliary ridge, and a fracture of the left clavicle by a fall from his horse. High Bridge, Virguiia, April 8th, 1865. Admitted to Officers’ Hospital, Point of Rocks, Virginia, April 14th. Loss of vision of the left eye resulted, but whether from division of the supra-orbital nerve, or derangement of the optical apparatus caused by the concussion, was not determined. The fractured clavicle united and the wounds healed. He was discharged from service June 16th, 1865, and placed on the Pension List. On September 4th, 1867, he was reported as suffering from the permanent loss of the left eye ; but without other disability. Benntltt, Edward H., Corporal, Co. F, 2d New York Cavalry, received a slight sabre-cut on the right side of the scalp, at New Market, Virginia, October 19th, 1863. Admitted to Lincoln Hospital, Washington, October 21st, and transferred October 31st. Bennett, Thomas F., Private, Co. K, 10th Virginia Cavalry, received a sabre-cut of the scalp at Gettysburg, July 2d, 1863. Admitted to Seminary Hospital, Gettysburg, July 3d, and transferred thence to David’s Island, New York Harbor, on July 17th, and on August 24th, being entirely well, he was pafoled and sent to Fort Monroe for exchange. Benton, H. L., Private, Co. G, 1st Massachusetts Cavalry. Sabre-cut of the scalp. Aldie, Virginia, June 17th, 1863. Returned to duty September 25th, 1863. Bertrajm, Harry, Corporal, Co. K, 6th Ohio Cavalry, aged 30 years. Sabre-cut of the left occipital region two inches in length. Sheridan’s Raid, May 12th, 1864. Admitted to Hammond Hospital, Point Lookout, Maryland, May 16th. Returned to duty June 28th, 1864. Best, Thomas W., Private, Co. A, 6th Pennsylvania Cavalry. Sabre-cut of the right occipital region. Admitted to Second Division Hospital, Annapolis, Maryland, June 14th, 1863. Deserted July 7tli, 1863. His name was on the Pension List September 4th, 1867, his disability being rated as “ total and temporary.” Bigger, Samuel T., Private, Co. C, 1st Delaware Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to Tilton Hospital, Wilmington, Delaware, July 4th. Returned to duty, well, August 22d, 1863. INCISED AND PUNCTUEED WOUNDS. 3 Bu'STJsrs, John, Private, Co. K, 1st Alabama Cavalry, received a slight sabre-cut of the scalp at Moore’s Cross Koads, North Caroliua, March 10th, 1865. Mustered out of service July 19th, 1865. • Bohije, Charles, Bugler, Co. I, 18th Pennsylvania Cavalry. Sabre-cut of the left parietal region, and a wound of the arm. Hagerstown, Maryland, July 6th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, August 3d. Deserted October 15th, 1863. Boileau, Jajies P., Private, Co. A, 1st Delaware Volunteers, aged 21 years. Sabre-cut of the scalp. Weldon Eail- road, Virginia, August 25th, 1864. Admitted to Tilton Hospital, Wilmington, Delaware, November 1st, from Harewood Hos- pital, Washington. Eeturned to duty November 14th, 1864. Bolton Marvin, Corporal, Co. G, 1st Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to Jarvis Hospital, B.iltimore, July 20th. Transferred to Carver Hospital, Washington, July 23d. Eeturned to duty November 17th, 1863. Boulson, Edward F., Sergeant, Co. B, 5th Michigan Cavalry. Sabre-cut of the occipital region. Trevillian Station, Virginia, June 12th, 1864. Missing in action. Died at Andersonville, Georgia, August 15th, 1864. Bourne, L., Private, Co. K, 51st Virginia Infantry. Sabre-cut of the scalp. Opequan Creek, Virginia, September 19th, 1864. Admitted to Field Hospital, Winchester, Virginia, on the same day. Eecovered and transfeiTed for exchange December 20th, 1864. Boyer, Joseph C., Captain, Co. L, 12th Tennessee Cavalry, aged 28 years. Sabre-cut of the forehead, received in a hand to hand fight with a rebel officer of General Forrest’s command. Nashville, December 16th, 1864. Mustered out of service October 7 th, 1865. Bradford, Jaahss, Private, Company B, 3d Pennsylvania Cavalry, sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to Field Hospital July 7th. Transferred to Satterlee Hospital, Philadelphia, July 9th. Eeturned to duty July 27th, 1863. Brees, Theodore J., Private, Co. L., 2d United States Cavalry. Sabre-cut of the scalp, and gunshot wound of left hand. Culpeper, Virginia, August 1st, 1863. Admitted to Douglas Hospital, Washington, August 3d. Transferred to Carlisle Barracks September 11th, 1863, and returned to duty. Brenage, Lafayette, Sergeant, Co. D, 21st Pemisylvania Cavalry. Sabre-cuts of the scalp and face. Jettcrsville, Vir^ia, April 5th, 1865. Admitted to Cavalry Corps Hospital April 12th. Eeturned to duty April 18th, 1865. Briggs, William H., Private, Co. M., 5th Michigan Cavalry, aged 17 years. Sahre-cuts of the scalp and right ear. Lynchburg, Virginia, June 11th, 1864. Admitted to Mount Pleasant Hospital, Washington, Jime 20th. Eeturned to duty July 26th, 1864. Brill, William, Private, Co. H, 15th New York Cavalry, aged 18 years. Sabre-cuts of the scalp. Winchester, Vir- ginia, November 15th, 1864. Admitted to hospital at Annapolis Junction, Maryland, January 4th, from Patterson Park Hospi- tal, Baltimore. Eeturned to duty March 25th, 1865. Brooks, J. K., Sergeant, Co. C, 1st Maine Cavalry. Sahre-cut of right side of scalp. Rliddleburg, Virginia, June 19th, 1863. Admitted to Emory Hospital, Washington, June 21st. Eeturned to duty July 3d, 1863. Brown, James, Private, Co. H, 1st Maryland Volunteers, aged 34 years. Sahre-cut of the scalp, while on picket at Hatcher’s Eun, Virginia, March 20th, 1865. Admitted to Satterlee Hospital, Philadelphia, April 7th, from Lincoln Hospital, Washington. Furloughed April 25th, 1865. Discharged from service July 10th, 1865. Brown, Jasper, Private, Co. D, 5th Michigan Cavalry. Sabre-cuts of the scalp and neck. Hanover, Pennsylvania, June 30th, 1863. Admitted to hospital at Gettysburg July 3d. Transferred to Pattei-son Park Hospital, Baltimore, November 11th. Eeturned to duty February 24th, 1864. Brown, R. H., Private, Co. K., 1st Arkansas Cavalry, aged 18 years. Sabre-cut of the scalp. Osage, Missouri, October 25th, 1864. Admitted to hospital at Fort Scott, Kansas, October 28th. Eeturned to confinement November 30th, 1864, and subsequently exchanged. Bryan, George P., 1st Lieutenant, Co. G, 2d North Carolina Eegiment. Sabre-cut of the scalp. Upperville, Virginia, June 2l8t, 1863. Admitted to Stanton Hospital, Washington, June 23d. Sent to Old Capitol Prison August 1st, 1863, and subsequently exchanged. Buck, Dennis M., Sergeant, Co. D, 2d United States Cavalry, aged 32 years. Sahre-cut of the scalp. Trevillian Station, Virginia, June 11th, 1864. Admitted to Finley Hospital, Washington, June 21st. Eeturned to duty, well, August 22d, 1864. Burroughs, Harmon, Commissary Sergeant, 8th New York Cavalry, aged 17 years. Sabre-cut, four inches in length, over the left parietal region. Beverly Ford, Virginia, June 9th, 1863. Admitted to Lincoln Hospital, Washington, June 10th. Eeturned to duty July 4th, 1863. Butcher, Eobkrt A., Private, Co. H, 82d Pennsylvania Volunteers, of the 3d Brigade, 1st Division, 0th Corps, aged 21 years, received, in an encounter with the enemy’s cavalry near Burke’s Station, Virginia, on April 6th, 1865, two sabre-cuts over the vertex, parallel to each other, and at right angles to the sagittal suture. The wounds appeared to implicate the 8C.alp only, and were approximated by adhesive plaster, after the hair had been shaven away. The patient was conveyed to 4 WOUNDS AND INJURIES OE THE HE 2 VD, Wiisliiiigton, and entered Harevvood Hospital on April lOtli. The wounds healed rapidly, and no unpleasant symptoms occurred until May 29th, when he complained of severe headache, accompanied by intolerance of light and sensitiveness to noise. A day or two subsequently the anterior wound reopened, and discharged thin unhealthy pus. An exfoliation was suspected, but no denuded bone could be detected, and under a mild evacuant treatment the headache subsided, and the wound again assumed an healthy aspect. On June 8th, 1805, it had almost entirely healed, and, at his own I'equest, the patient was discharged from the hosjiital and from the service of the United States. Soon after his admission to Harewood, a jdiotograph of his w'ounds had been taken, by direction of the surgeon in charge, Brevpt Lieut. Col. E. B. Bontecou, U. S. Vols. This is preserved as No. 30 of the first volume of Photographs of Surgical Cases, Army Medical Museum, and is very faithfully copied in the figure on the left of the grou]) of heads in the accompanying plate. Cain, Patrick, Private, Co. G, ()2d New York Volunteers, aged 38 years. Sabre-cut of the scalp. Cold Harbor, Vir- ginia, June 3d, 1864. Admitted to McKim’s Mansion Hospital, Baltimore, June 11th. Eeturned to duty August 3d, 1864. Campbelr, Haeri.son G., Private of Co. 5th United States Cavalry, aged 25 years, was wounded in action near Louisa Court House, Virginia, on May 4th, 1863, and fell into the hands of the enemy. He was exchanged, and sent to Annapolis on the hospital transport State of Maine, and was admitted to the general hospital at that place on May 17th, with two suppurating sahre wounds of the scalp, one over the light parietal eminence, the other behind the left ear. He had head- ache, with frequent jmlse, constipated bowels, and ajipeared to be very feeble. He was purged, and then ordered good diets and “whiskey and (piinine frealy.” On May 20th erysipelas attacked the left leg, which had received no injury. Tincture ot iodine locally and tincture of the sesquichloride of iron internally were employed to combat this complication. On May 21st there was epistaxis ; the pulse was small, at 110; the tongue heavily coated. On the 23d there was diarrhoea, which was controlled by pills of ojiium and camphor. The next day the pulse had risen to 120, and was soft. The abdomen w'as tympanitic. Stimulants were freely given. The catheter was resorted to, on account of retention of urine, which was scanty and high colored, and oil of turpentine, in doses of ten drops, thrice daily, was ordeied. On the 28th the erysipelatous inflam- mation had extended up the back and over the right leg. The teeth were covered with sordes. Turpentine, with carbonate of ammonia and whiskey and concentrated nutriment, and tincture of iodine locally, constituted the treatment. On June 6th, the erysipelas had extended to the face and throat, and the patient became delirious. He continued in ah unconscious state until .June 14th, 1863, when he died. Acting Assistant Surgeon J. M. Matlock, who reports the case, ascribes the fatal event to “ exhaustion following typhoid erysipelas,” and as unconnected with the scalp wounds, which maintained an healthy appearance to the last. Capron, Jaimes P., Sergeant, Co. E, 3d United States Artillery. Sabre-cut of the forehead, and a shell wound of the left side of the neck. Bisland, Louisiana, April 14th, 1863. Discharged from service July 26th, 1864. Carbough, Daniel, Private, Co. E, 18th Pennsylvania Cavalry, aged 46 years. Sabre-cut of the right parietal region, in a skirmish on the Eapidan, Virginia, November 17th, 1863. Admitted to Douglas Hospital, Washington, November 23d. Transferred to Satterlee Hospital, Philadelphia, November 28th. Eeturned to duty March 24th, 1864. Carey, William H., Private, Co. G, 15th New York Cavalry, aged 18 years. Sabre-cut of the scalp. Newmarket, Virginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Discharged from service May 20th, 1865. Carney, William, Private, Co. L, 2d New York Cavalry. Sabre-cut of the scalp, and a shell and gunshot wound of the upper third of the right thigh. Aldie, Virginia, June 17th, 1863. Admitted to Hospital No. 1, Annapolis, Maryland, June 22d. Died .Tune 22d, 1863, from the effects of the gunshot injury. Carper, Philip W., Private, Co. A, 35th Virginia Cavalry. Sabre-cut of the left parietal region ; also a wound of the right arm and left hand. Brandy Station, Virginia, June 9th, 1863. Admitted to Second Division Hospital, Alexandria, Vir- ginia, June 10th. Transferred to Old Capitol Prison .June 17th, 1863, for exchange. Carson, W. L., Private, Co. B, 10th New York Cavalry, aged 21 years. Sabre-cut of the scalp. Admitted to Second Division Hospital, Annapolis, Marj-land, June 22d, 1863. Discharged from service September 17th, 1864. Cebutt, George, Private, Co. F, 11th United States Infantry, aged 19 years. Sahre-cut of the right parietal region. Petersburg, Virginia, August 17th, 1864. Admitted to First Division Hospital, Annapolis, Maryland, August 24th. Deserted November 10th, 1864. Chambers, James M., Private, Co. K, 14th Pennsylvania Cavalry, aged 18 years. Sabre-cut of the scalp. Millwood, Virginia, December 17th, 1864. Admitted to hospital at Annapolis Junction, Maryland, January 4th, 1865. Dischai-ged fi’om service May 30th, 1865. Chambers, John, Private, Co. I, 1st Michigan Cavalry. Sabre-cut of the left side of the head. Gettysburg, July 1st, 1863. Admitted to Fort Schuyler Hospital, New York Harbor, July 15. Eeturned to duty August 28, 1863. Chan, H., Private, Co. P, 2d Georgia Cavalry. Sabre-cut of the head. Admitted to hospital, Petersburg, Virginia, December 10th, 1862. Fuiloughed, December 19th, 1862. CiiANTRELL, OcTAVE, Private, Co. M, 4th Now York Cavalry. Sabre-cut of the scalp and of the light arm. Upper- villo, Virginia, June 21st, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 9th, 1863. Chapman, Samuel, Chaplain, Mosby’s command. Sabre-cut of the head. Dranesville, Virginia, Aju il 1st, 1863. Clemens, A., Private, Co. C, 51st Virginia Infantry. Sabre-cut of the scalp. Oiiequan Creek, Virginia, Sejitember 19th, 1864. Admitted to Field Hospital, Winchester, Virginia, September 20th. Transferred for exchange, well, November, 1864. Med.» S'urg. Hist , of die Wur of the Kebellidn, I'art I. Vol U. Op page *1 ‘00 cs INCISED AND PUNCTURED WOUNDS. 5 Clemmens, Lawrence, Bugler, Co. I, 1st Massachusetts Cavalry, aged 27 years. Sabre-cut of the scalji. Adiuitted to Judiciary Square Hospital, Washington, February 20th, 1804. Deserted March 24th, 1864. Coclcrill, Q. J., Private, Co. G, 5th Alabama. Sabre-cut of the head. Petersburg, Virginia, April 2d, 1805. Admitted to Lincoln Hospital, Washington, April 10th. Sent to Old Capitol Prison, April 25th, 1865, for exchange. Colley, John, Private, Co. E, 2d West Virginia Cavalry, aged 20 years. Sabre-cut of the left parietal region. Five Forks, Virginia, April 2d, 1805. Admitted to Slough Hospital, Alexandria, Virginia, June 7th. Discharged from service June 20th, 1865. CoLLVER, Edward A., Private, Co. B, 2d New York Cavalry. Sabre-cut of the left occipital region, two and a half inches in length. Brandy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, AnnapolE, Maryland, June 14th. Returned to duty August 10th, 1864. Connelly', Thomas, Sergeant, Co. I, 1st United States Cavalry, aged 47 years. Sabre-cut of the scalp, and fracture of lower third of the left arm. W^ajmesboro’, Virginia, September 28th, 1864. Admitted to Chestnut Hill Hospital, Phila- delphia, October 9th, and, after several transfers, was admitted to hospital at Carlisle Barracks, Pennsylvania, and discharged from service June 3d, 1865. Conner, Charles, Private, Co. I, 5th Oliio Cavalry, aged 45 years. Sabre-cut of the scalp. Fayetteville, North Carolina, March 10th, 1865. Admitted to Dennison Hospital, Cincinnati, Ohio, April 15th. Discharged from service July 19th, 1865. Conover, Ralph, Private, Co. H, 18th Pennsylvania Cavalry. Sabre-cuts of the head and neck. Hanover, Pennsyl- vania, June 30th, 1863. Admitted to Satterlee Hospital, Philadelphia, July 4th. Returned to duty September 23d, 1863. COREY', Leander a., ISIusician, Co. K, 2d New York Cavalry, aged 21 years. Sabre-cut of the scalp. Admitted to Judiciary Square Hospital, AVashington, February 8th, 1864. Returned to duty March 14th, 1864. CORSTION, Robert, Private, Co. H, 1st Michigan Cavalry, aged 19 years. Sabre-cut of the right pai-ietal region. Smithfield, Virginia, August 29th, 1864. Admitted to Jarvis Hospital, Baltimore, Maryland, September 4th. Returned to duty October 1st, 1864. Couch, Daniel, Private, Co. F, 1st Massachusetts Cav'alry. Sabre-cut of the scalp, and pistol wound of the abdomen. Aldie, Virginia, June 17tli, 1863. Admitted to Armory Square Hospital, Washington, July 3d. Transferred to Lovell Hospital, Portsmouth Grove, Rhode Island, July 8th. Returned to duty September 21st, 1863. Cowley, Frank, Corporal, Co. G, 6th United States Cavalry. Sabre-cut of the scalp. Fairfield, Pennsylvania, July 3d, 1883. Admitted to hospital at Gettysburg July 22d. Returned to duty September 11, 1863. Coyne, Thomas, Corporal, Co. B, 10th New York Cavalry. Sabre-cut, two and a half inches in length, over the left occipital region; also a wound of light side of face. Brandy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Returned to duty October 19th, 1863. Craft, J. H., Private, Co. H, 60th Virginia Infantry. Sabre-cut of the scalp. Opequan Creek, Virginia, September 19th, 1864. Admitted to Field Hospital at AVinchester, Virginia, the same day. Transferred for exchange December 10th, 1864, well. Crane, Jajies, Private, Co. A, 0th Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to Satterlee Hospital, Philadelidiia, July 10th. Returned to duty September 23d, 1803. Crocker, Jay*, Private, Co. D, 10th New A’ork Cavalry. Sabre-cut of the left parietal region, two and a half inches in length, directly over the parietal eminence. Brandy Station, Virginia, June 9th, 1803. Admitted to Hospital No. 1, Annapolis, Maryland, June 14th. Returned to duty August 15th, 1863. Crodon, John, Private, Co. C, 23d Illinois Volunteers. Sabre-cut of the forehead. Annapolis, Maryland, May 21st, 1863. Admitted to First Division Hospital the same day. Returned to duty June 12th, 1863. Cusack, AVilllvji, Captain, Co. I, 96th Pennsylvania A^olunteers, aged 34 years. Sabre-cut of the forehead over the left eye. Spottsylvatiia, A^'irginia, May 8th, 1864. Admitted to Seminary Hospital, Georgetown, District of Columbia, May 12th. Discharged from service J uly 28th, 1804. CUTTICR, AVilliam, Private, Go. H, 4th Vermont Infantry, aged 38 years. Sabre-cut of the scalp. Strasburg, A'^irginia, August 16th, 1864. Admitted to Field Hospital at Sandy Hook, Maryland, August 19th, and transfemul to Bratlleboro’, Ver- mont, February 6th, 1865, for muster out of service. Dancer, George W., Private, Co. A, 0th Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, Pennsylvania, July 1st, 1863. Admitted to Satterlee Hospital, Philadelphia, July 10th. Returned to duty August 0th, 1863. De Graw, Isa^vc, Private, Co. A, 0th Michigan Cavalry. Sahre-cut of the scalp. Gettysburg, July list, 1863. Admitted to Satterlee Hospital, Philadelphia, July 10th. Returned to duty September 23d, 1863. De Groot, Henry', Private, Co. A, 17th Connecticut Volunteers. Sahre-cut on the left side of the scalp. Admitted to Knight Hospital, New Haven, Connecticut, January 23d, 1864. Transfi'rred to Fort Trumbull I’ebruary 27th, 1804, for duty. Dela-MATER, IL, Corporal, Co. M, 15th New A’ork Cavalry, aged 24 years. Sahre-cut of the scalp. Newmai-ket, Virginia, December 21st, 1834. Admitted to hospital at Frederick, Maryland, December 23d. Retui-ned to duty January 31st, 1865. 6 WOUNDS AND INJURIES OF THE HEAD, DiiNiiURST, H., Private, Co. D, 17th Connecticut Volunteers. Sabre-cut of the scalp. Gettysburg, July Ist, 1863. Admitted to Seminary Hospital, Gettysburg, same day. Transferred to South Street Hospital, Pliiladelphia ; thence to Knight Hospital, New Haven, Connecticut, on March 24th, 1864. Returned to duty April “21st, 1864. Dodd, Thomas, Sergeant, Co. B, 6th United States Cavalry. Sabre-cut over the anterior and posterior regions of the scalp. Funktown, Maryland, July 7th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, August 3d. Returned to duty, well, October l‘2th, 1863. Donun, John, Private, Co. K, 6th Pennsylvania Cavalry. Sabre-cut of right parietal region. Admitted to First Division Hospital, Annapolis, Maryland, June 14th, 1863. Returned to duty June 17th, 1863. Dougherty, Patrick, Private, Co. A, 6th United States Cavalry. Sabre-cut of the left forehead, two inches above the eye. Brandy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Discharged fi-om “service October 12th, 1864. Douglas, Joseph, Private, Co. A, 6th Michigan Cavalry. Sabre-cut of the scalp and left shoulder. Gettysburg, July 3d, 1863. Admitted to Hospital No. 1, Annapolis, Maryland, July 16th. Returned to duty July 31st, 1863. Downs, Adam, Private, Co. G, 1st Pennsylvania Cavalry. Sabre-cut of the scalp. New Hope Church, Virginia, Novem- ber 27th, 1863. Admitted to Regimental Hospital the same day, and returned to duty December 5th, 1863. Doyle, Joseph C., Private, Co. A, 1st Alabama Cavalry. Sabre-cut of the scalp, received on Sherman’s campaign through the Carolinas, 1865. Mustered out of service with regiment October 20th, 1865. Doyea, John, Private, Co. K, 1st Maine Cavalry, aged 22 years. Sabre-cut of the occipital region. Brandy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Returned to duty August 1st, 1863. ^ Drew, Horace W., Sergeant, Co. A, 6th Ohio Cavalry, aged 25 yeai-s. Sabre-cut, two inches in length, of the right frontal region. Ashland Station, May 12th, 1864. Admitted to Hammond Hospital, Point Lookout, Maryland, May 16th. Ti-ansferred to the Veteran Reserve Corps, May 4th, 1865. Mustered out of service August 24th, 1865. Drew, J. H., Private, Co. F, 45th North Carolma. Sabre-cut of the head. Gettysburg, July 1st, 1863. Admitted to Hospital No. 1, Frederick, Maryland, July 6th. Transferred to Annapolis July 7th, 1863, for exchange. Dunn, Willis, Private, Co. F, 35th Virgmia Infantry. Sabre-cut of the right parietal region. Brandy Station, Virginia, June 9th, 1863. Admitted to Second Division Hospital, Alexandria, Virginia, June 10th. Transferred to Old Capitol Prison, Washington, June 12th, 1863, for exchange. Duchet, J., Private, Co. E, Thomas’s Legion. Sabre-cut of the scalp. Opequan Creek, Virginia, September 19th, 1864. Admitted to Field Hospital, Winchester, Virginia, September 20th. Transferred for exchange December 20th, 1864, entirely well. Dudley, C. V., 1st Lieutenant, Co. K, 15th Virginia Cavalry, aged 25 years, received several sabre-cuts of the scalp, and ■ one of the right side, at Culpeper, Virginia, September 13th, 1863. Admitted to Lincoln Hospital, Washington, September 17th. Recovered, and was transferred to the Old Capitol Prison October 19th, 1863, for exchange. Dursten, Thomas, Quartermaster Sergeant, 15th New York Cavalry, aged 20 years. Sabre-cut of the scalp. New- market, Virginia,, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty February 1st, 1865. Dustan, George L., Private, Co. G, 1st Maine Cavalry, aged 25 yeare. Sabre-cut of the scalp over the occipital region, Br.andy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Returned to duty October 25th, 1864. Edmunds, Howard, Captain, Co. L, 3d Pennsylvania Cavalry. Sabre-cut of the scalp, and gunshot wound of the shoulder. Gettysburg, July 3d, 1863. Discharged from service August 24th, 1864. His name is not on the Pension List. Edwards, David, Corporal, Co. H, 5th Ohio Cavalry. Sabre-cut of the scalp. Sherman’s campaign through the Carolinas, 1865. Mustered out of service October 30th, 1865. Edwards, William A., Private, Co. B, 5th United States Cavalry. Sabre-cut of the left parietal region. Chancellors- ville, Vu-ginia, May 4th, 1863. Admitted to Second Division Hospital, Annapolis, Maryland, May 19th. Deserted August 7th, 1863. Ells, William S., Private, Co. K, 9th New York Cavalry. Sabre-cut of the scalp and right arm. Culpeper, Virginia, August 1st, 1863. Admitted to Douglas Hospital, Washington, August 3d. Returned to duty October 10th, 1863. Eynatten, Francis, Sergeant, Co. I, 198th New York Volunteers. Sabre-cut of the face extending from the ang'j of the mouth to the superior portion of the forehead. Pleasant Hill, Louisiana, April 9th, 1864. He was taken prisoner and admitted to a rebel hosjutal, and the wound closed with sutures. Discharged fi-om service April 20th, 1866. Fagle, Frederick, Private, Co. C, 10th New York Cavalry. Two sabre-cuts on the vertex of the scalp, one of the left cheek, and one of the left shoulder. Brandy Station, Virginia, June 9th, 1863. Admitted to Fii-st Division Hospital, Annapolis, Maryland, June 14th. Returned to duty May 2d, 1864. Filler, Joseph, Private, Co. A, 4th New York Cavalry. Sabre-cuts of the scalp and wrist. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, Washington, June 23d. Returned to duty July 25th, 1863. INCISED AND PUNCTUEED WOUNDS. t Fink, Anthony, Private, Co. G, 15th New York Cavalry, aged 35 years. Sabre-cut of the scalp. Newmarket, Virginia,' December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Eeturned to duty January 3d, 1865. Finnigan, W., Private, Co. L, 4th New York Cavalry. Sabre-cut of the scalp. Aldie Gap, Virginia, June 17th, 1863. Admitted to Third Division Hospital, Alexandria, Virginia, June 18th. Furloughed July 22d. Returned to duty August 22d, 1863. Fishkr, Charles W., Private, Co. C, 3d Pennsylvania Cavalry. Sabre-cut of the right occipital region while attempt- ing to escape fiom the patrol guard at Annapolis, Maryland, March 29th, 1863. Admitted to Hospital No. 1, at Annapolis, the same day. Eeturned to duty April 13th, 1863. Foley, Miles, Sergeant, Co. B, 3d Pennsylvania Cavalry. Sabre-cuts of the scalp and arm. Gettysburg, July 1st, 1863. Admitted to Satterlee Hospital, Philadelphia, July 9th. Eeturned to duty July 13th, 1863. Folsom, William M., Private, Co. E, 5th Wisconsin Volunteers, aged 31 years. Sabre-cut of the scalp and hand. July 20th, 1864. Admitted to Harvey Hospital, Madison, Wisconsin, August 1st. Eeturned to duty August 7th, 1864. Fox, Elias, Private, Co. G, 15th New York Cavalry, aged 26 years. Sabre-cut of the scalp. Newmarket, Virginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty January 21st, 1865. Fox, Jasper C., Private, Co. L., 14th Pennsylvania Cavalry, aged 18 years. Sabre-cut of the scalp. Millwood, Virginia, December 17th, 1864. Admitted to McKim’s Hospital, Baltimore, January 15th, 1865. Eeturned to duty March 20th, 1865. Foster, Joshua E., Private, Co. M, 6th Pennsylvania Cavalry. Sabre-cut of the right parietal region. Admitted to Second Division Hospital, Annapolis, Maryland, August 21st, 1863. Eeturned to duty October 14th, 1863. Frisbie, Samuel, Private, Co. E, Ringgold’s Battalion, aged 23 years. Sabre-cut .of three inches in length extending diagonally across the parietal region. September 16th, 1863. Admitted to hospital at Cumberland, Maryland, September 16th. Deserted October 16th, 1863. Frontman, Philip, Private, Co. L, 14th Pennsylvania Cavalry, aged 18 years. Sabre-cut of the scalp. Millwood, Virgmia, December 17th, 1864. Admitted to Field Hospital, Winchester, Virgmia, December 20th. Eeturned to duty January 17 th, 1865. Gardner, George, Private, Co. K, 17th Veteran Reserve Corps, aged 21 years. Sabre-cut of the head. Indianapolis, Indiana, January 5th, 1865. Admitted to City Hospital, in that place, January 12th, from Soldiers’ Home. Eeturned to duty J anuary 23d, 1865. Gardner, William, Private, Co. H, 15th New York Heavy Artillery, aged 26 years. Sabre-cut of the scalp. South Side Railroad, Virginia, March 31st, 1865. Admitted to White Hall Hospital, Pennsylvania, May 27th, from Lincoln Hospital, Washington. Discharged fi-om service July 22d, 1865. Gatewood, C. T., Private, Co. F, 9th Virginia Cavalry. Sabre-cut of the scalp. Gettysburg, Pennsylvania, July 1st, 1863. Admitted to hospital at David’s Island, New York Harbor, July 17th. Transferred for exchange, well, August 24th, 1863. Geiirett, James W., Private, Co. D, 1st Louisiana Artillery, aged 33 years. Sabre-cut of the scalp. Cedar Creek, Virguiia, October 19th, 1864. Admitted to McClellan Hospital, Pliiladelphia, October 24th. Eeturned to duty November 24th, 1864. Giddings, Benjamin, Private, Co. G, 1st Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 3d, 1863. Admitted to Jarvis Hospital, Baltimore, July 19th. Transferred to Carver Hospital, Washington, July 23d. Returned to duty October 20th, 1863. Gilbert, Nahum, Sergeant, Co. I, 1st Michigan Cavalry, aged 24 years. Sabre-cut of the head, and a penetrating gunshot wound of the abdomen by a conoidal ball which entered at the umbilicus. Gettysburg, July 1st, 1863. Admitted to Camp Letterman Hospital, Gettysburg, July 6th. Fmcal discharges took place from the wound in the abdomen. Much pain and difficulty in micturition. July 7th, paralysis of lower extremities. August 28th, wounds healed. September 1st, paralysis of lower extremities continues, together with partial paralysis of the rectum. The treatment consisted of com- presses and bandage to the abdomen, with diuretics and enemata. Transferred to Mulberry Street Hospital, Harrisburg, Sep- tember 15th. Discharged from service October 31st, 1863. Good, Martin, Private, Co. M, 2d United States Cavalry, aged 22 years. Sabre-cut of the scalp. Beverly Ford, Vir- ^nia, June 9th, 1863. Admitted to Satterlee Hospital, Philadelphia, June 23d. Deserted October 1st, 1863. Goodall, Charles, Private, Co. B, 5th Georgia Cavalry, aged 42 years. Sabre-cut of the left frontal region. Woodbury, Tennessee. Admitted to Hospital No. 1, Murfreesboro, Tennessee, September 6th, and transferred for exchange, well, Septem- ber 12th, 1864. Goodman, George N., Private, Co. E, 21st Virginia Cavalry, aged 19 years. Sabre-cut of the scalp. Front Royal, Virginia, November 12th, 1864. Admitted to West’s Building Hospital, Baltimore, November 17th. Transferred to Fort McHenry, Baltimore, December 9th, 1864, for exchange. Graves, William, Private, Co. G, 46th Virginia Infantry, aged 42 years. Sabre-cut of the scalp. Petersburg, Virginia, June 17th, 1864. Admitted to Emory Hospital, Washington, June 24th. Transferred to Lincoln Hospital June 26th, and thence to the Old Capitol Prison for exchange, October 26th, 1864. 8 WOUNDS AND INJUEIES OF THE HEAD, Gi:ay, Elijah G., Private, Co. F, Ist ^lieliigaii Cavalry, aged 25 years. Sabre-cut of the head, and wound of breast by ))istol ball. Gettysburg, July 1st, 18CI5. Admitted to Satterlee Hospital, Pbiladelpbia, July 9tb. Returned to duty December 23d, 18G3. Gkeen, John, Sergeant, Co. D, 18tb New York Cavalry, aged 20 years. Sabre-cut of the scalp. Alexandria, Louisiana, April 21st, 1864. Admitted to Marine Hosj)ital, New Orleans, Louisiana, May 23d. Furloughed June 18th, 1864. Deserted August 31st, 1865. Giheein, Stephen, Private, Co. B, 2d Massachusetts Cavalry, aged 23 years. Sabre-cuts of the scalp and left ear. Rockville, Maryland, July 18th, 1864. Admitted to Campbell Hospital, Washington, July 21st. Transferred thence to Lovell Hospital, Portsmouth Grove, Rhode Island, July 28th. Returned to duty August 23d, 1864. GitiFFiTii, G. W., Private, Co. G, 2d United States Cavalry, aged 23 years. Sabre-cut, an inch and a half long, of the left frontal region. Culpeper, Virgini.a, August 1st, 1863. Admitted to Douglas Hospital, Washington, August 2d. Returned to duty August 14th, 1863. Hand, CTiaeles F., Ih-ivate, Co. F, 2d United States Cavalry. Sabre-cut, two inches in length, of the occipital region. Brandy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Returned to duty October 26th, 1863. Hanna, John, Private, Co. I, 6th Michigan Cavalry, aged 25 years. Sabre-cut of the scalp. Gettysburg, July 2d, 1863. Admitted to Satterlee Hospital, Philadelphia, July 9th. Returned to duty July Jlst, 1863. Harmon, Martin, Sergeant, Co. I, 9th New Yoi-k Cavalry. Sabre-cut of scalp. Rapidan, Virginia, October 11th, 1863. Admitted to Regimental Hospital, and returned to duty October 11th, 1863. Harvey, Joshua, Sergeant, Co. I, 60th Virginia Infantry, aged 40 years. Sabre-cut of the scalp. Winchester, Virginia, September 19th, 1864. Admitted to West’s Building Hospital, Baltimore, October 19th. Transferred for exchange, well, October 25th, 1864. Haskell, David E., Sergeant, Co. F, 8th New York Cavalry. Sabre-cut of the scalp. Beverly Ford, Virginia, June 9th, 1863. Admitted to Lincoln Hospital, Washington, June 11th. Returned to duty June 17th, 1863. Hazelet, Lewis, Private, Co. L, 14th Pennsylvania Cav.alry, aged 38 years. Sabre-cuts of the scalp and arm. Mill- wood, Virginia, December 17th, 1864. Admitted to McKim’s Mansion Hospital, Baltimore, January 15th, 1865, from Field Hospital. Transferred to Mower Hospital, Pliiladelphia, Febi'uary 10th. Returned to duty February 23d, 1865. IIiGGiNSON, Henry Lee, Major, 1st IMassachusetts Cavalry. Sabre-cuts of the scalp and neck. Aldie Gap, Virginia, June 17th, 1863. Admitted to First Division Hospital, Alexandria, Virginia, June 24th. Dischai’ged from service, well, August 9th, 1864. Hobbs, J. F., Private, Co. M, 1st Rhode Island Cavalry. Sabre-cut of the scalp and right shoulder. Kelley’s Ford, Virginia, March 17th, 1863. Admitted to Fii'st Division Hospital, Annapolis, Maryland, Api-il 6th. Returned to duty October 5th, 1863. Hood, Thomas, Sergeant, Co. E, 6th United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Discharged July 28th, 1864, on exjiiration of term of service. IloitSEFiELD, James, Private, Co. K, 73d Indiana Volunteers, aged 49 years. Sabre-cut of the scalp. May 11th, 1864. Admitted to Second Division Hospital, Madison, Indiana, November 28th. Returned to duty March 17th, 1865. IIoi’.TON, L. P., Private, Co. L, 10th New York Cavalry. Sabre-cut of the scalp. Virginia, May 11th, 1884. Hosey, William, Private, Co. A, 8th New Jersey Volunteers, aged 34 years. Sabre-cut of the scalp. Chancellorsville, Virginia, May 3d, 1863. Admitted to Mower Hospital, Philadelphia, April 27th, ,1864, from Tilton Hospital, W^ilmington, Dela- ware. Transferred to Trenton, New Jersey, for muster out, August 26th, 1864. Hguse, Wesley L., Corporal, Co. A, 1st United States Cavalry. Sabre-cut, one inch in length, of the left occipital region. Biandy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Returned to duty December 2d, 1863. Huckehy, Bobert A., Private, Co. I, 53d Georgia Infantry, aged 27 years. Sabre-cut of the scalj). Cedar Creek, Virginia, October 19th, 1864. Admitted to West’s Building Hospital, Baltimore, October 24th. Died October 26th, 1864, of “chronic diarrhoea.” Huntley, Ira, Private, Co. C, 2d Kentucky Cavalry, aged 23 years. Three sabre-cuts of the scalp. Cynthiana, Ken- tucky, June 12th 1864. Admitted to Seminary Hospital, Covington, Kentucky, June 13th. Meningitis, with serous effusion, supervened, and death resulted on June 21st, 1864. Ingraham, Chauncey, Private, Co. K, 4th New York Cavalry, aged 23 years. Sabre-cut of the scalp. Upperville, Virginia, June 21st. Returned to duty Sejdember 28th, 1863. Received a similar wound at Fiont Royal, Virginia, August 16th, 1864. Admitted to Camp Parole Hosj)ital, Annapolis, Maryland, October 7th. Deserted, while on furlough, November 18th, 1864. Jacobs, A. B., Private, Co. H, 6th United States Cavalry. Sabre-cut of the scalp. Fairfield, Pennsylvania, July 3d, 1863. Admitted to Camden Street Hospital, Baltimore, August 29th. Transferi'ed to Cuyler Hospital, Germantown, Pennsyl- v.ania, October 27th. Returned to duty December 3d, 1863. INCISED AND PUNCTURED WOUNDS. 9 JoxES; William,. Private, Co. L, Gth United States Cavalry. Sabre-cut of the scalp and arm. Fairfield, Pennsylvania, July 3d, 1863. Admitted to West's Building Hos])ital, Baltimore, July ’iOth. Transferred to Carver Hospital, Washington, July 24th. Returned to duty September 11th, 1863. Kellea', Jefferson, Corporal, Co. K, 6th Michigan Cavalry, .aged 21 years. Sabre-cut of the scalp aud face. Yellow Tavern, Virginia, June 11th, 1864. Admitted to !Mt. Pleasant Hospital, Washington, June 21st. Returned to duty September 13th, 1864. Kella’, .Iosepii, Serge.ant, 1st New Jersey Cavalry. Sabre-cut of the scalp. Beverly Ford, Virginia, June 9th, 1863. As no further record can be found of this case, the injury was ju'obably trivial. Mustered out Sej)tember 16th, 1864. Kemp, Alfred, Sergeant, Co. H, 7th Michigan Cavalry. Sabre-cut of the scalp and neck. Gettysburg, July 3d, 1863. Admitted to Jarvis Hospital, Baltimore, July 19th. Transferred to Detroit, Michigan, October 19th. Discharged May 2d, 1864. Kenla', MTlliaji, Private, Co. F, 4th New York Cavalry. Sabre-cuts of the head and hand. Aldie Gap, Virginia, June 17th, 1863. Admitted to Third Division Hospital, Alexandria, Virginiti, June 20th. Discharged from service February 19th, 1864. , Kern, Frederick, Private, Co. D, 4th New York Cavalry. Sabre-cut of the scalp and chest. Front Royal, Virginia, August 16th, 1864. Discharged from service June 1st, 1865. Kidwell, Philip, Private, Co. C, 3d Virginia Mounted Infantry, aged 23 years. Sabre-cut of the scalp. Cumberland, Maryland, July 11th, 1863. Admitted to hospital at Cumberland the same day, and returned to duty November 18th, 1863. Kiernlan, Michael, Private, Co. A, Gth United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, Washington, June 24th. Furloughed July 12th. Returned to duty August 13th, 1863. King, Samuel, Private, Co. H, 149th Pennsylvania Volunteers, aged 33 years. Sabre-cut of the scalp. Cold Harbor, Virginia, June 1st, 1864. Admitted to Convalescent Hospital, Philadelphia, June 11th. Transferred to Harrisburg, Pennsyl- vania, September 23d, and returned to duty October Gth, 1864. Kirby, Andrew H., Private, Beckham’s Battalion. Sabre-cut of the scalp. Admitted to Lincoln Hospital, W’^ashington, September 17th, 1863. Transferred for exchange October 19th, 1863. Kirkpatrick, William, Private, Co. M, 14th Pennsylvania Cavalry, aged 45 years. Sabre-cut of the scalp. Mill- wood, Virginia, December 17th, 1864. Admitted to Camden Street Hospital, Baltimore, December 22d. Transferred to Phila- delphia March 12th, 1865. Discharged from service May 16th, 1865. Klim, William J., Private, Co. L, 1st Maryland Cavalry. Sabre-cut of the left frontal region. Chambersburg, Pennsj’lvania, July 28th, 1864. Admitted to Yoi’k Hospital, Pennsylvania, August 3d. Returned to duty September 15th, 1864. Knox, Benj.vmin E., Sergeant, Co. B, 2d New York Cavalry. Sabre-cut, an inch and a half long, over occipital pro- tuberance. Brandy Station, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, June 14th. Returned to duty October 19th, 1863. Lago, William, Private, Co. L, 14tlr Pennsylvania Cavalry, aged 22 years. Sabre-cut of the right side of the seal]). Millwood, Vir’ginia, December 17th, 1864. Admitted to Patter-son Park Hospital, Baltimore, March 3d. Returned to duty March 8th, 1865. Leahy, John, Sergeant, Co. D, 13th Pennsylvania Cavalry. Sabre-cut of the left side of the head. Admitted to Hos- pital No. 1, Annapolis, Maryland, March 8th, 1863. Deserted April 7th, 1863. Returrred from desertion April 30th, 1863, and ordered to report to Colorrel Waite, Military Commander at Annapolis. Leavitt, Frank W., Pr-ivate, Co. E, 1st Maine Cavalry, aged 25 years. Three sabre-cuts on left, ceirtre, and back of the head, and pistol wound through left side of upper lip. Brandy Station, Virginia, June 9th, 1863. Admitted to Hospital No. 1, Annapolis, June 15th. Returned to duty Septendier 13th, 1863. Lee, Jeremiah, Private, Co. K, Gth I’ennsylvania Cavalry. Sabre-cut of right occipital region. Culpeper, Virginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Tran.sferred to Philadelphia October 3d, 1863. He was discharged, and his application for a pension was rejected May 13th, 1864, his wound having produced no disabilitj'. Lee, Thomas, Private, Co. C, 14th Pennsylvania Cavalry, aged 22 years. Sabre-cut of the left side of the scalp. P'ive I orks, Virginia, April 2d, 186.5. Admitted to Slough Hospital, Alexandria, Virginia, .June Gth. Discharged from service .June 29th, 1885. a. O. Xo. 77, A. G. 0., April 28th, 1865. Little, Jicsse IL, Private, Co. B, 18th Pennsylvania Cavalry. Sabre-cuts of the head and shoulder. Hanover, Penn- sylvania, .June 30th, 18.i3. Aihnittod to Satterlee Hospit.al, Philadelphia, July 9th. Returned to duty .January 22d, 1864. Lockwood, S., Private, Co. K, 1st United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, Washington, June 23d. Returned to duty July 13th, 1863. Logan, M. M., Sergeant, Co. M, 16th Pennsylvania Cavalry, aged 21 years. Seven sabre-cuts of the scalf), one of the right shoulder, one of the left forearm, and a pistol-shot wound of the right hip. Aldie, Virginia, .June 18th, 1863. Admitted to Lincoln Hospital, Washington, June 21st. Returned to duty January 17th, 1864. Lotz. William L., Private, Co. L, 1st Pennsylvania Cavalry, aged 17 years. Sabrc-ciit of the right side of the scalp 2 10 WOUNDS AND INJURIES OF THE HEAD, Near Richmond, Virginia, May 9tli, 1864. Admitted to Hammond Hospital, Point Lookout, Maryland, May 16th. Returned to duty July 19th, 1864. Lowry, Isaac, Private, Co. C, 11th Georgia Infantry, aged 23 years. Sabre-cut of the scalp. Fisher’s Hill, Virginia, October 19th, 1864. Admitted to hospital at Point Lookout, Maryland, January 3d, 1865. Transferred for exchange, well, February 11th, 1865. Lucas, Willard H., Private, Co. B, 1st Maine Cavalry, aged 28 years. Sabre-cut of scalp. Yellow Tavern, Virginia, May 12th, 1864. Transferred to United States Navy July 4th, 1864. Lunt, Albert C., Private, Co. I, 1st Vermont Cavalry. Sabre-cut of the left parietal region, two inches above the ear ; also one of the vertex. Dranesville, Virginia, April 1st, 1863. Admitted to Hospital No. 1, Annapolis, April 8th. Trans- ferred to Brattleboro’, Vermont, July 29th ; thence to Bedloe’s Island, New York Harbor, November 8th. Returned to duty November 16th, 1863. Lutes, James W., Private, Co. F, 1st Michigan Cavalry. Sabre-cuts of forehead and vertex of scalp. Gettysburg, July 3d, 1863. Admitted to First Di^sion Hospital, Annapolis, Maryland, July 16th. Returned to duty August 15th, 1863. Luther, James, Private, Co. G, 8th Illinois Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Recovered, and re-enlisted in the Veteran Reserve Corps. Mustered out of service July 17th, 1865. Luther, Nicholas, Private, Co. B, 21st Veteran Reserve Corps, aged 49 years. Sabre-cut of forehead. Troy, New York, while on guard. Admitted to hospital at Albany, New York, August 24th. Returned to duty September 26th, 1864. Lyons, Jajies, Private, Co. E, 18th Pennsylvania Cavalry. Sabre-cut of the scalp. Hanover, Pennsylvania, June 30th, 1863. Admitted to Jarvis Hospital, Baltimore, July 14th, and transferred to First Division Hospital, Annapolis, Mary- land, July 16th. Returned to duty August 11th, 1863. Mack, John, Private, Co. E, 1st Connecticut Cavalry, aged 26 years. Sabre-cut of the scalp. Cedar Creek, Virginia, October 17th, 1864. Admitted to Field Hospital at Sandy Hook, Maryland, October 21st. Transferred to Satterlee Hospital, Philadelphia, October 27th. Returned to duty December 1st, 1864. Mann, Nehemiah H., Captain, Co. M, 4th New York Cavalry. Sabre-cut of the scalp, and gunshot flesh wound of chest. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, Wasliington, June 23d. Returned to duty Sep- tember 29th, 1863. McAlexander, D., Private, Co. G, 21st Virginia Cavalry, aged 18 years. Sabre-cut of the scalp. Front Royal, Virginia, November 9th, 1864. Admitted to West’s Building Hospital, Baltimore, November 16th. Transferred for exchange, well, December 9th, 1864. McCabe, George, Private, Co. C, 2d Maryland Cavalry. Sabre-cut of the left parietal region. Monocacy, Maryland, July 9th, 1864. Admitted to West’s Building Hospital, Baltimore, September 3d. TransfeiTed to Fort McHenry, Baltimore, for exchange, well, September 24th, 1864. McClellan, Williaji T., Private, Co. B, 12th Pennsylvania Cavalry, aged 24 years. Sabre-cut of the scalp. Raid on Hamilton, Virginia, March 21st, 1865. Admitted to hospital at Harper’s Ferry, Virginia, March 25th. Transferred to Cumberland, Maryland, April 6th. Returned to duty April 24th, 1865. McCool, Michael H., Sergeant, Co. B, 71st New York Volunteers, aged 30 years. Sabre-cut of the scalp. Chancel- lorsville, Virginia, May 3d, 1863. Admitted to Turner’s L.ane Hospital, Philadelphia, March 14th. Discharged from service May 17th, 1864. McCoy, John, Private, Co. K, 9th Indiana Cavalry, aged 29 years. Incised wound of the scalp. In an aflfray. Admitted to hospital at Indianapolis, Indiana, April 13th. Returned to duty May 6th, 1864. McDowell, James, Private, Co. H, 6th United States Cavalry. Sabre-cut of the scalp. Fairfield, Pennsylvania, July 3d, 1863. Admitted to First Division Hospital, Annapolis, Maryland, August 3d. Returned to duty August 15th, 1863. McFall, .Jonatilan, Private, Co. A, 6th Michigan Cavalry. Sabre-cuts of the scalp and shoulder. Gettysburg, July 1st, 1863. Admitted to Satterlee Hospital, Philadelphia, July 10th. Returned to duty December 4th, 1863. McKenna, Davenport, Private, Co. G, 14th Pennsylvania Cavalry, aged 21 years. Sabre-cut of the scalp. Mill- wood, Virginia, December 17th, 1864. Admitted to Camden Street Hospital, Baltimore, December 21st. Returned to duty February 23d, 1865. McKowen, William, Corporal, Co. G, 1st Maryland Cavalry. Sabre-cut of the forehead, and one on the back of the neck. Culpeper, Virginia, September 3d, 1863. Admitted to First Division Hospital, Annapolis, Maryland, September 24th. Returned to duty November 9th, 1863. McLean, William, Captain, Co. H, 5th United States Cavalry. Two or three sabre-cuts of the posterior portion of the scalp. Hanover, Virginia, June 13th, 1862. Taken prisoner, and confined in Libby Prison, Richmond, for a few weeks, when he was released. Died of inflammation of the brain April 13th, 1863. McVeigh, T. E., Corporal, Co. F, 15th Virginia Cavalry. Sabre-cut, three inches in length, of the superior occipital region. Brandy Station, Virginia, June 9th, 1863. Admitted to Prince Street Hospital, Alexandria, June 10th. Transferred to provost marshal June 12th, 1863, for exchange. INCISED AND PUNCTURED WOUNDS. 11 Meagher, Edward, Private, Co. M, Cth United States Cavalry. Sabre-cut of the scalp. Fairfield, Pennsylvania, July 3d, 1833. Discharged September 2Gth, 1864, on expiration of term of service. Meredith, D. H., Private, Co. C, 1st Delaware Cavalry, aged 28 years. Sabre-cut of the scalp ; also gunshot wound of the left leg. Westminster, Maryland, June 29th, 1863. Admitted to Tilton Hospital, Wilmington, Delaware, July 4th. Transferred to Mower Hospital, Philadelphia, April 27th, 1864. Returned to duty July 11th, 1864. Might, Johx, Private, Co. E, 6th United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, Washington, June 24th. Returned to duty August 13th, 1863. Miller, Fraxk E., Sergeant, Co. B, 1st New York Cavalry. Sabi’e-cuts of the scalp and ear. Dinwiddle Coui t House, Virginia, March 31st, 1865. Recovered, and mustered out with his regiment June 27th, 1865. Miller, John W., Private, Co. L, 14th Pennsylvania Cavalry, aged 22 years. Sabre-cut of the scalp. Ashby’s Gap, Virginia, February 9th, 1865. Admitted to hospital at Frederick, Maryland, March 1st, 1865. Discharged from service July 10th, 1865. Mills, W’^. S., Private, Co. F, 1st Michigan Cavalry. Sabre-cut of the scalp and shoulder. Gettysburg, J uly 1st, 1863. Admitted to Broad and Cherry Streets Hospital, Philadelphia, July 15th. Returned to duty August 12th, 1863. Montgomery, John, Private, Co. F, 18th Pennsylvania Cavalry, aged 20 years. Sabre-cut of the occipital region. Hanover Junction, Pennsylvania, June 30th, 1863. Admitted to Cuyler Hospital, Germantown, Pennsylvania, July 5th. Returned to duty December 10th, 1863. Morris. J., Private, Co.. H, 1st Virginia Artillery, aged 20 years. Sabre- wound of the scalp. Lynchburg, Virginia, June 13th, 1864. Admitted to Post Hospital, New Creek, West Virginia, June 20th. Returned to duty July 6th, 1864. IMortsolf, Martin, Corporal, Co. C, 10th New York Cavalry. Three sabre-cuts — one of forehead, one of right arm, and one of back, extending from left shoulder to right hip. Brandy Station, Virginia, June 9th, 1863. Admitted to Prince Street Hospital, Alexandria, June 10th. Returned to duty July 6th, 1863. Nellis, John, Corporal, Co. A, 6th Ohio Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Nelman, , Private, Co. B, Irish Dragoons, Fremont’s Body Guard. Sabre-cut of the scalp and several bruises. Springfield, Jlissouri, October 25th, 1861. As no further record can be found of this case, the injuries were probably tr ivial. Newkirk, Jajies C., Private, Co. C, 1st Delaware Cavalry. Sabre-cut of the scalp. Westminster, Maryland, June 29th, 1863. Admitted to Tilton Hospital, Wilmington, Delaware, July 4th. Returned to duty August 25th, 1863. O'Connell, C., Private, Co. C, 5th Illinois Cavalry. Sabre-cut of the scalp. Ellisville, Mississippi, June 23d, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 15th. Returned to duty September 17th, 1863. Odell, Charles L., Private, Co. B, 86th New York Volunteers. Sabre-cut of the scalp. Beverly Ford, Virginia, June 9th, 1863. Admitted to Lincoln Hospital, Washington, June 11th. Returned to duty June 24th, 1863. O’Neil, Thomas, Private, Co. I, 1st Maryland Cavalry, aged 24 years. Accidental incised wound of the scalp. Admitted to Jarvis Hospital, Baltimore, March 11th, 1864. Returned to duty April 14th, 1864. Overton, George P., Private, Co. E, 15th New York Cavalry, aged 41 years. Sabre-cut of the scalp. Newmarket, Virginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty January 21st, 1865. Palmer, David, Private, Co. K, 6th Oliio Cavalry, aged 19 years. Sabre-cut of right occipital region. Yellow Tavern, Vir^uia, May 12th, 1864. Admitted to hospital at Point Lookout, Maryland, May 16th. Returned to duty June 28th, 1864. Parcells, Joseph A., Private, Co. F, 3d Pennsylvania Cavalry, aged 22 years. Sabre-cut of the head, and also over the right clavicle. Gettysburg, July 2d, 1863. Admitted to Chester Hospital, Pennsylvania, July 9th, 1863. Returned to duty December 23d, 1863. Parris, George W., Private, Co. D, 5th New York Cavalry. Sabre-cut of the scalp. September 13th, 1863. Admitted to Armory Square Hospital, Washington, September 14th. Returned to duty December 4th, 1863. Patterson, John, Private, Co. B, 1st United States Cavalry. Sabre-cut of the right side of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Hospital No. 1, Annapolis, July 15th. Returned to duty August 15th, 1863. Phetteplace, Madison, Private, Co. I, 23d Ohio Volunteers, aged 35 years. Sabre-cut of the scalp. Cedar Creek, Virginia, October 19th, 1864. Admitted to Satterlee Hospital, Philadelphia, October 23d. Transferred to Tripler Hosjwtal, Columbus, Ohio, June 28th. Mustered out of service July 7th, 1865. Pickett, Thomas, Private, Co. I, 2d Maine Cavalry. Sabre-cut of left side of scalp. Pino Barrens, Florida, October, 1864. Admitted to Regimental Hospital, and returned to duty the same day. Pool, George S., Private, Co. F, 1st Michigan Cavalry. Sabre-cut of the head and right wrist. Gettysburg, .July 1st, 1863. Admitted to Broad and Cherry Streets Hospital, Philadeljihia, July 15th. Discharged from service October 3d, 1863. PORTELL, Patrick, Private, Co. B, 10th Massachusetts Volunteers. Sabre-cut of the right side of the head, one inch above the frontal protuberance. Gettysburg, J uly 3d, 1863. Admitted to Satterlee Hospital, Philadelphia, J uly 5th. Returned to duty April 22d, 1864. Pullen, T. E., Lieutenant, Co. G, 15th Virginia Cavalry, aged 30 years. Sabre-cut of the occipital region. Admitted to Chimborazo Hospital, Richmond, Virginia, May 17th. Returned to duty June 20th, 1864. 12 WOUNDS AND INJUEIES OF THE HEAD, Putnam, Oijrin J., Corporal, Co. I, 1st Vermont Cavalry, aged 24 years. Sabre-cut of left side of file scalp. Dranes- ville, Virginia, April 1st, 1863. Admitted to First Division Hospital, Annapolis, Maryland, April 8th. Transferred to Invalid Corps, ^Marcli loth, 1864, and mustered out on expiration of his term of service. Pye, Oliver, Private, Co. K, 1st New Hampshire Cavalry, aged 37 years. Sword wound of the scalp. Newtown, Virginia, November 12th, 1864. Admitted on the same day to the Cavalry Corps Hospital, and transferred November 20th to McKim's Mansion, Baltimore, Died December 10th, 18()4, of “effects of sabre wound,” Quinn, Michael, Bugler, Co, D, 4th United States Cavalry, aged 19 years. Sabre-cut of the scalp, Franklin, Ten- nessee, November 30th, 1864. Admitted to No. 15 Hospital, Nashville, December 23d. Returned to duty January 4th, 1865. Quinn, Peter, Private, Co. B, 17th Veteran Reserve Corps, aged 43 years. Severe incised wound of the scalp. Acci- dental. Admitted to hospital, Indianapolis, Indiana, June 23d, from Ekin Bawacks. Returned to duty October 27th, 1864. Remington, George W., Captain, Co. H, 2d New York Cavalry, aged 24 years. Sabre-cut of the scalp. Mount Jackson, Virginia, November 22d, 1864. Admitted to Field Hospital at Sandy Hook, Maryland, November 30th. Clustered out on expiration of term of service, June 5th, 1865. Rice, Horatio H., Sergeant, Co. A, 10th New York Cavalry, aged 24 years. Sabre-cut of the scalp, and a gunshot flesh wound of the thigh. Trevillian Station, June 11th, 1864. Admitted to Mount Pleasant Hospital, Washington, June 21st, 1864. Transferred to Satterlee Hospital, Philadelphia, June 29th. Discharged December 7th, 1864, on account of expiration of term of enlistment. Richardson, E., Private, Co. B, 2d Georgia Cavalry. Sabre-cut of the head. Admitted to rebel hospital, Petersburg, Virginia, December 10th, 1862. Returned to duty December 23d, 1862. Richie, J. R. F., Private, Co. H, 12th Virginia Cavalry. Sabre wound of the head. Admitted to Chimborazo Hospital, Richmond, Virginia, June 12th, 1863. Furloughed June 24th, 1863, for sixty days. Robinson, Charles E., Ihivate, Co. C, 9th Virginia Cavalry, aged 43 years. Sabre-cut of the parietal region three inches in length. UppervUle, Virginia, June 21st, 1863. Admitted to Stanton Hospital, Washington, June 23d. Transferred to Old Capitol Prison August 16th, 1863, for exchange. Robinson, WTlliaji, Commissaiy Sergeant, 2d Ohio Cavalry. Sabre-cut of the scalp. September, 1864. Mustered out of service September 11th, 1865. Rogers, George A., Private, Co. H, 1st Vermont Calvary. Sabre-cut of the scalp. Brandy Station, Virginia, October 11th, 1863. Admitted to hospital at Annapolis, October 29th; transferred to Brattleboro, Vej'mont, December 9th; transferred to Baxter Hospital, Burlington, December Kith. Returned to duty February 25th, 1864. Rowie, James II., Private, 5th Virginia Cavalry. Sabre-cut of the scalp. Aldie Gap, Virginia, June 17th, 1863. Paroled. Ruffin, Thomas, Major, 1st North Carolina Cavalry. Sabre wound of the head. Admitted to Hospital No. 4, Richmond, Virginia, July 22d, 1863. Furloughed .July 29th, 1863. Russell, George, Sergeant, Co. I, 1st Maine Cavalry, aged 21 years. Sabre-cut of the scalp. Sheridan’s Raid in Vir- ginia, May, 1864. Discharged the service August 17th, 1864. Ryan, Jeremiah, Private, Co. H, 22d New York Cavalry, aged 24 years. Sabre-cut of the scalp. Admitted to De Camp Hospital, David’s Island, New York Harbor, June 3d, 1865. Discharged from service July 15th, 1865. Ryan, Saxey, Sergeant, Co. G, 13th Indiana Volunteers, aged 23 years. Sabre-cut of the scalp. Bermuda Hundred, Virginia, June 19th, 1864. Admitted to Filbert Street Hospital, Philadelphia, July 6th. Transferred to Satterlee Hospital July 16th. Returned to duty August 6th, 1864. Salisbury, Frederick, Private, Co. C, 10th New York Cavalry. Sabre-cut of the left parietal region. Beverly Ford, Virginia, June 9th, 1863. Admitted to Second Division Hospital, Annapolis, Maryland, June 14th. Returned to duty July 24th, 1863. Saunders, Edward, Private, Co. AI, 7th Michigan Cavalry, aged 18 years. Sabre-cut of the occipital region. Front Royal, Virginia, August 16th, 1864. Admitted to Jarvis Hospital, Baltimore, Maryland, August 21st. Returned to duty Sep- tember 27th, 1864. Saxton, Edward P., Private, Co. D, 6th Pennsylvania Cavalry. Sabre-cut of the scalp. Beverly Ford, Virginia, .June 9th, 1863. Admitted to Second Division Hospital, Annapolis, Maryland, June 14th. Returned to duty June 18th, 1863. Schaefer, Gustavus, Priv.Tte, Co. B, 12th Pennsylvania Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to Satterlee Hospital, Philadelphia, July 9th. Returned to duty August 11th, 1863. SciiEER, WiLLiAJi, Private, Co. M, 2d United States Cavalry. Sabre-cut of the right parietal region. Beverly Ford, Virginia, June 9th, 1863. Admitted to Second Division Hospital, Annapolis, June 14th. Returned to duty July 27th, 1863. SCHiEViLBiEN, Edward, Corporal, Co. F, 3d Indiana Cavalry. Sabre-cut of the scalp. Admitted to Field Hospital, Hope’s Landing, Virginia, March 23d, 1863. Discharged in consequence of aberration of mind, resulting from the injury, April 12th. 1863. Secrer, James, Sergeant, Co. C, 1st United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863.- Admitted to Tilton Hospital, Wilmington, Delaware, August 12th. Returned to duty October 2d, 1863. I^ICISED AND PUNCTURED WOUNDS. 13 Shaw, C. C., Private, 1st Virginia Cavalry, aged 18 years. Sabre-cut of the left parietal region. Warrenton, Virginia, May 3d, 18C3. Admitted to ^Mansion House Hospital, Alexandria, Virginia, May 3d, 18G3. Transferred for exchange, well, June 15tli, 18G3. SiiEPiiEUD, Heubekt L., Private, Co. 11, 1st Massachusetts Cavalry. Sabre-cut, two inches in length, of the right parietal region, and slight cut of the hand. Manassas Gap, Virginia, June 17th, 18G3. Admitted to First Division Hospital, Annapolis, Maryland, July IGth. Returned to duty October 5th, 18G3. Shotwei.l, Joiix, Sergeant, Gtli Kentucky Cavalry. Sabre-cut of the scalp. Sherman’s Campaign through the Caro- linas, 1865. Sheffield, John, Private, Co. D, 1st Arkansas Cavalry, aged 18 years. Sabre-cut of the forehead. Osage, Missouri, October 25th, 18G4. Admitted to hospital at Fort Scott, Kansas, October 28th. Returned to confinement November 17th, 1864. Subsequently exchanged. Singleton, William, Piivate, Co. B, Kith New York Cavalry. Sabre-cut of the scalp. Near Opelousas, Louisiana, October 22d, 1863. Admitted to hospital at New Orleans, November 11th. Returned to, duty December 3d, 1863. Skid, John, Private, Co. A, 6th Michigan Cavalry, aged 27 years. Sabre-cut of the scalp. Gettysburg, July, 1863. Admitted to Satterlee Hospital, Philadelphia, July 9fh. Returned to duty November 27th, 1863. Small, John F., Sergeant, Co. H, 1st United States Cavalry. Sabre-cut of the left parietal region. Upperville, Vir- ginia, June 21st, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 15th. Returned to duty September 26th, 1863. Smith, Geobge W., Private, Co. D, 1st Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to hospital at Gettysburg .July 2d. Returned to duty July 9th, 1863. S.MITH, PIeney M., Private, Co. C, 11th Pennsylvania Volunteers, aged 34 years. Sabre-cut of the scalp. Wilderness, Virguiia, May 5th, 1864. Admitted to hospital at Pittsburg June 23d. Returned to duty March Ist, 1865. Smith, John B., Private, Co. K, 6th Pennsylvania Cavalry. Sabre-cut of the scalp. Beverly Ford, Virginia, June 9th, 1863. As no further record can be found of this case, the injury was probably trivial. Smith, Patkick, Private, Co. A, 8th New York Cavalry, aged 21 years. Sabre-cut of the scalp. Lacey’s Springs, Virginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty January 21st, 1865. Southeeland, Joseph, Private, Co. D, 1st Illinois Artillery, aged 22 years. Sabre-cut of the scalp. December 25th, 1864. Admitted to hospital at Nashville, Tennessee, the same day. Returned to duty January 4th, 1865. Staff, Isaac, Private, Co. H, 14th Pennsylvania Cavalry. Sabre-cut of the scalp. Millwood, Virginia, December 17th, 1864. Stanton, C. S., Private, Co. D, 2d United States Cavalry, aged 23 years. Sabre-cut of the scalp. Winchester, Virginia, September 19th, 1864. Admitted to hospital at Frederick, Maryland, October 12th. Returned to duty December 3d, 1864. Steakem, M., Private, Co. 1, 16th Massachusetts Volunteers. Sabre-cut of the scalp. Gettysburg, July, 1863. Admitted to South Street Hospital, Philadelphia, July 8th. Returned to duty July 27th, 1863. Steinhausee, J., Private, Co. C, 1st United States Cavalry, aged 22 years. Sabre-cut, two and a half inches long, of the right temporal region; also a wound of the thoracic parieties. Culpeper, Virginia, August 1st, 1863. Admitted to Douglas Hospital, Washington, August 2d. Returned to duty October 17th, 1863. Stellman, Chaeles, Private, Co. B, 6th Ohio Cavalry. Sabre-cut of the scalp. Beaver Dam, Virginia, May, 1864. Stevens, Daniel, Private, Co. I, 36th Virginia Infantry, aged 34 years. Sabre-cut of the scalp. Winchestei-, Virginia, September 19th, 1864. Admitted to West’s Building Hospital, Baltimore, October 13th. Transferred for exchange October 17th, 1864. Sti.mpson, Robeet E., Private, Co. G, 1st Michigan Cavalry, aged 20 years. Sabre-cut of the head. Gettysburg, July 2d, 1863. Admitted to Satterlee Hospital, Philadelphia, July 9th. Returned to duty September 23d, 1863. Steuble, L. G., Corpoi’al, Co. A, 5th Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to Fort Schuyler Hospital, New York Harbor, July 15th. Transferred to De Camj) Hospital, David’s Island, February 9th, 1864. Returned to duty February 20th, 1864. Sl’LHAm, Jonas G., Private, Co. I, 1st Vennont Cavalry, aged 40 years. Sabre-cut of the left side of head; also gun- shot wound of right side of head, and two bruises of right side of scalp by a revolver barrel. Di'anesville, Virginia, April 1st, 1863. Admitted to Hospital No. 1, Annapolis, April 8th. Returned to duty May 1st, 1863. He was captured June 9th, 1864, and died in a southern piison. Swain, D. P., Sergeant, Co. A, 6th Michigan Cavalry. Sabre-cut of the scalp. Hunterstown, Pennsylvania, .July 2d, 1863. Recovered and returned to duty. Subsequently he was captured, and died in prison at Andersonville, Georgia. Taesaei, Adolphus, Private, Co. B, 12th New York Cavalry, aged 19 years. Sabre-cuts of the scalp and right hand; September 29th, 1864; for the latter, amputation of the index finger was performed. June 27th, 1865. Admitted to McDougall Hospital, New York Harbor, .July 9th. Deserted August 3d, 1865. 14 WOUNDS AND INJURIES OF THE HEAD Taylor, C. M., Private, Co. D, Jeff. Davis Legion. Sabre-cut of the occipital region ; also a gunshot w'ound of left arm. Ujiperville, Virginia, June 21st, 1863. Admitted to Stanton Hospital, Washington, June 23d. Transferred for exchange August 1st, 1863. Tewksbuky, Benjamin P., Private, Co. E, 3d New York Cavalry, aged 46 years. Sabre-cut of the head, and contu- sion of the back by a fall from his horse. Ream’s Station, Virginia, June 2Dth, 1864. Admitted to Balfour Hospital, Portsmouth, Virginia, from Regimental Hospital, May 24th, 1865. Discharged July 20th, 1865. Thomas, J. IF., Sergeant, Co. A, 1st Georgia Cavalry. Sabre-cut of the head. Admitted to hospital at Petersburg, Virginia, November 18th, 1862. Returned to duty December 2d, 1862. Thompson, C. S., Lieutenant, Co. E, 2d South Carolina Cavalry. Sabre- wound of the head. Admitted to Hospital No. 4, Richmond, Virginia, August 6th, 1863. Furloughed August 12th, 1863. Thompson, John, Private, Co. C, 7th Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 3d, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 16th. Returned to duty August 26th, 1863. Thompson, William H., Private, Co. K, 18th Alabama Infantry, aged 24 years. Sabre-cut of the scalp. Nashville, Ten- nessee, December 15th, 1864. Admitted to hospital at NashvUle December 25th, 1864. Transferred to Provost Marshal January 3d, 1865, for exchange. Tomein, John F., Captain, Co. M, 3d New Jersey Cavalry. Sabre-cut of the scalp. Sailor’s Run, Virginia, April 6th, 1865. Admitted to Cavalry Corps Hospital April 11th. Furloughed April 18th. Mustered out of service August 1st, 1865. Towiste, Edward O., Corporal, Co. D, 1st Massachusetts Cavalry, aged 39 years. Sabre-cut, three inches in length, behind the right ear. Aldie, Virginia, June 17th, 1863. Admitted to Third Division Hospital, Alexandria, Virginia, Jime 18th. Furloughed July 18th, 1863. Returned to duty and mustered out with regiment October 3d, 1864. Townslee, Giles, Private, Co. A, 6th Michigan Cavalry. Sabre-cuts of the scalp and left arm. Hunterstown, Penn- sylvania, July 2d, 1863. Admitted to Satterlee Hospital, Philadelpliia, July 10th. Returned to duty September 23d, 1863. Trauer, William D., Private, Alabama Reserves, aged 47 years. Sabre-cut of the scalp. Milton, Florida, December 24th, 1864. Admitted to St. Louis Hospital, New Orleans, Louisiana, December 28th. Transferred to Military Prison March 11th, 1865, for exchange. Tweedale, T., Private, Co. I, 1st United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, Washington, June 23d. Returned to duty September 11th, 1863. Updyke, Everett C., Private, Co. D, 10th New York Cavalry. Sabre-cut of the right occipital region, three inches in length. Brandy Station, Virginia, June 9th, 1863. Admitted to Hospital No. 1. Annapolis, June 14th. Returned to duty August 15th, 1863. Updyke, J. R., Private, Co. B, 5th New York Cavalry. Sabre-cut of the scalp, and gunshot wound of the hip. Han- over, Pennsylvania, June 30th, 1863. Admitted to Fort Schuyler Hospital, New York Harbor, July 15th. Returned to duty August 28th, 1863. Walker, John B., Private, Co. K, 36th Virginia Infantry, aged 38 years. Sabre-cut of the scalp. Winchester, Virginia, September 19th, 1864. Admitted to hospital at Winchester the following day. Transferred to Baltimore December 11th. Sent to Fort McHenry January 5th, 1865, for exchange. Watson, John, Private, Co. H, 1st Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, Pennsylvania, Jidy, 1863. Admitted to South Street Hospital, Philadelphia, July 8th. Returned to duty July 27th, 1863. Watts, IF. C., Private, Co. D, 14th Virginia Cavalry, aged 26 years. Sabre-cut of the scalp. Front Royal, Vir^ia, November 12th, 1864. Admitted to Field Hospital, Winchester, Virginia, November 14th. Transferred to Fort McHenry December 9th, 1864, for exchange. Weed, William H., Private, Co. C, 2d West Virginia Cavalry. Sabre-cut of the scalp. Five Forks, Virginia, April Ist, 1865. Mustered out of service June 3d, 1865. Wegman, Jacob, Private, Co. I, 16th Illinois Cavalry. Sabre-cut of the scalp. Accident. Admitted to West End Hospital, Cinemnati, Ohio, October 26th. Returned to duty December 19th, 1863. Welch, Henry L., Private, Co. B, 6th Michigan Cavalry. Sabre-cut of the scalp. Front Royal, Virginia, August 16th, 1864. Deserted June 23d, 1865. Wentworth, George A., Private, Co. G, 2d Massachusetts Cavalry, aged 24 years. Sabre-cut of the scalp. . Aldie, Virginia, July 6th, 1864. Admitted to Third Division Hospital, Alexandria, Virginia, July 12th. Returned to duty September 12th, 1864. Wilson, Dana S., Private, Co. K, 6th Michigan Cavalry, aged 32 years. Sabre-cut of the scalp. Front Royal, Vir- ginia, August 16th, 1864. Admitted to Field Hospital at Sandy Hook, Maryland, August 18th. Transferred August 20th, 1864. Recovered and returned to duty. Subsequently died of chronic diarrhoea, November 13th, 1865. Wilson, M. D., Private, Co. H, 14th Virginia Cavalry, aged 20 years. Sabi'e-cut of the scalp. Front Royal, Virginia, November 12th, 1864. Admitted to Field Hospital, Winchester, Virginia, November 14th. Transferred to Baltimore November 16th, and thence to Fort McHenry, December 9th, 1864, for exchange. WiNGROVE, George, Private, Co. F, 9th New York Heavy Artillery. Sabre-cut of the right parietal region. Shep- INCISED AND PUNCTUEED WOUNDS. 15 herdstown, Virginia, August 25th, 1864. Admitted to Patterson Park Hospital, Baltimore, August 27th. Transferred to Camp Parole August 29th. Eetm-ned to duty October 5th, 1864. Winters, August, Private, Co. kl, 5th Ohio Cavalry, aged 23 years. Sabre-cut of the scalp, and shell-wound of the ann. Near Fayetteville, North Carolina, March lOth, 1865. Admitted to Grant Hospital, New York Harbor, March 30th. Transferred to Camp Dennison, Ohio, April 10th. Discharged from service June 23d, 1805. Wood, Samuel, Sergeant, Co. L, 2d New York Cavalry. Sabre-cuts of the occipital and parietal regions; also wound of neck. Culpeper Court House, Virginia, September 13th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, September 24th. Transferred to De Camp Hospital, New York Harbor, October 29th. Furloughed October 31st. Returned to duty November 21st, 1863. Woodson, W. It., Private, Co. B, 15th Virginia Cavalry, aged 27 years. Sabre-cut of the occipital region, five inches in length. Brandy Station, Virginia, October 11th, 1863. Admitted to Hammond Hospital, Point Lookout, Maryland, November 8th, from Campbell Hospital, Washington. Transferred for exchange, well, March 3d, 1864. Weigut, John, Private, Co. K, 1st Alabama Cavalry. Sabre-cut of the scalp. Sherman’s Campaign through the Carolinas, 1865. Wright, J. N., Private, Co. C, 1st Veimont Cavalry. Sabre-cut of the scalp on median line, three inches above the forehead, and pistol-shot wound of the thorax. Dranesville, Virginia, April 1st, 1863. Admitted to Hospital No. 1, Annapolis, April 8th. Returned to duty May 6th, 1863. Yeagle, Joseph, Private, Co. L, 5th New York Cavalry, aged 32 years. Sabre-cut of the scalp. Middleburg, Virginia, June 21st, 1863. Admitted to Stanton Hospital, Washington, June 25th. Retiu-ned to duty June 29th, 1863. Young, Seth, Private, Co. D, Ist Massachusetts Cavalry. Sabre-cut of the scalp, and gunshot wound of the left leg. Admitted to Lovell Hospital, Portsmouth Grove, Rhode Island, July 8th. Returned to duty November 18th, 1863. Of tlie two hundred and eighty-two cases of incised wounds of the scalp above recorded, six terminated fatally ; one hundred and sixty of the officers and men thus wounded were returned to duty, or transferred to the Veteran Reserve Corps for modified duty ; one officer resigned ; thirty-seven prisoners of war were placed in the custody of the Provost Marshal for exchange or parole ; fifty-one United States enlisted men were dis- charged from service on account of physical disability in a few instances only, and com- monly because of the expiration of their terms of enlistment ; twelve patients deserted ; four were furloughed from Confederate hospitals and did not return, and eleven remain unaccounted for, but undoubtedly recovered without disability, since their names do not appear on the mortuary records or the lists of applications for pensions. An examination of the record in each individual case indicates that the deserters and furloughed men, and the great majority of the discharged men and exchanged prisoners fully recovered, and that of the whole number of two hundred and eighty-two wounded, three died from some form of encephalitis directly’ resulting from the injuries received, while in five other cases, chronic diarrhoea, intemperate habits, or intercurrent diseases contracted in hospitals or prisons, were the proximate causes of the fatal issue. Cf those discharged for physical disability or invalided or pensioned, two suffered from mental aberration, others from vertigo, imperfect vision, headache, persistent pain at the seat of injury, ptosis, and amaurosis. Of those who recovered and were returned to duty, three were subsequently captured, and died from privation at Andersonville. In short, two hundred and sixty-three of the wounded recovered, eleven were temporarily or per- manently disabled, three died from complications, -and three from the direct results of the injury. The treatment of incised wounds of the scalp calls for few comments. Our surgeons commonly shaved a sufficient space about the wound, and after suppressing hajmorrhage, and, if necessary, cleansing the parts and removing foreign bodies, approximated the incised 16 WOUNDS AND INJURIES OF THE HEAD, parts Ly adhesive plasters.* A compress dipped in cold water and a retentive bandage were usually applied. Some surgeons were not averse to sutures, silver-wire sutures especially, and employed them without disadvantage in cases in which slanting sword cuts had raised flaps of integument. Surgeon S. W. Gross, U. S. V., alludesf to a case which came under his care during the war, but whidi has not been reported in detail, in which a large semilunar flap, raised from the vertex and side of the head, pi’esented a wound thirteen inches in length. He approximated the wound by nine points of silver suture. On the fourth day, union was perfect. There can be no doubt that exaggerated apprehensions have been entertained with respect to the employment of sutures in wounds of this class; but, as the scalp has but slight elasticity, and retracts but little after division, stitches are rarely indispensable. Heudorfer J makes the practical observation that when vjounds of the scalp are approximated by adhesive strips the lips are inverted, and the healing of the wound is long delayed by the growth of the hair. On this account he greatly prefers to unite such wounds by points of suture. Hennen and Guthrie and Adams § also sanction the employment of sutures in scalp wounds where there is much retraction of the edges. Whatever the mode of coaptation adopted, the importance of leaving sufficient intervals for the escape of discharges was generally recognized. There was not sufficient haemorrhage in any of the cases above enumerated to require the employment of ligatures. Pressure, which can be so conveniently applied over almost any part of the skull, was adequate to arrest bleeding in every instance. It does not appear that rest in bed, spare diet, and an antiphlogistic regimen, were often enjoined in this class of cases. It is probable that the unfavorable issue of a certain proportion of the cases was due to the neglect of these precautions. While many military surgeons of the present day call in question the rigid rules of the older surgeons for the general treatment of scalp wounds, and contest the utility of purging, of antimonials, of cold lotions, and of strict diet, none have the hardihood to deny that quiet and abstinence from stimulating food and drink are imperatively demanded in such cases. Incised Fractures of the Cranium. — Forty-nine cases of incised wounds of the head are recorded on the registers. They furnish illustrations of all the varieties of such injuries : the superficial marking of the outer table, the division of the outer table and diploe, the section of both tables and more or less profound penetration of the cranial cavity, and the separation of an osseous flap.|| Adams, J. F., Private, Co. G, 21st Virginia Cavalry, aged 34 years. Sabre fracture of the left parietal bone. Front Royal, Virginia, November 12tli, 1804. Admitted to hospital at Point Lookout, Maryland, January 31st, 1865, Transfen-ed for exchange, well, February 11th, 1865. Allen, Robert, Piivate, Co. I, 4th Kentucky Volunteers. Sabre fracture of the frontal bone over the external portion of the left orbital i-idge. Chickamauga, Georgia, September 20th, 1863. Admitted to hospital at Stevenson, Alabama, October 4th, 1863. Returned to duty October 22d, 1863. Mustered out August 21st, 1865. * Surgeons in the field were supplied with two kinds of “sticking plaster;” isinglass plaster (Emplastrum Icthyocollse) and adhesive plaster (Emplastrum Resinae, U. S. P.) The first was readily detached if water dressings were applied over it; the second was thought by many surgeons to be too irritating to be used in scalp wounds. French surgeons recommend strips of muslin spread with diachylon for the coaptation of these wounds. Strips of linen, secured at the ends by collodion, have also been employed. t Gross, (S. W.) Review of Worhs on Military Surgery, in Am. Jour, of Med. Scienres. N. S. Vol. LVI., p. 427, Octo- ber, 1867. INeudorfer. Ilandhuch der Kriegschirurgie. Leipzig, 1867. Zweite Halfte. ^ Hennen. Military Surgery, p. 286 ; Guthrie. Commentaries on the Surgery of the War, etc., 6th London ed., p. 387 ; Adams. Additions to Cooper’s Dictionary, 8th London ed., p. 374. 11 The \\jhimsical designations of these accidents by the older surgeons, as hedra, (superficial cut;) cceop6, (perpendicuhi.r cut); diacopk, (oblique section); and aposMparnismos, (detachment of portions of bone,) have become obsolete. INCISED EIIACTURES OE THE CRANIUM. 17 Akmstroxg, Maktix, Sergeant, Co. M, Ctli Unitetl States Cavalry. Sabre fracture of the ci-aniinn. I'airlield, Penn., July ‘Jd, ISCd. Admitted to First Division Hospital, Annapolis, Maryland, Septend)er20tli. Died October 4tli, 1863, of pya}niia. Bassek, Adam, Private, Co. F, 6th United States Cavalry, aged 27 years, received a sabre wound of the seal]) at Gettys- burg, July 3d, 1SG3. Admitted to hospital at Annapolis, Maryland, August 4th. Transferred to Annapolis Junction, April 9th, 1864; thence to Mower Hospital, Philadelphia, April 27th ; thence to Pittslmrg, June 7th, where it was found that then' rvas a loosened exfoliation of the outer table of the skull. This w’as removed; the wound then healed, and the man returned to duty, cured, July 22d, 1864. 13 , James F., Private, Co. F, 7th Michigan Cavalry, was captured at Gettysburg July 3d, 18,63, his horse being shot under him. He was hurried to the real- with other prisoners. In the subsequent retreat of the rebel army he was unable to keep up with the column, and, all efforts to goad him on being unavailing, a lieutenant in command of the provost guard cut him down, and left him for dead by the roadside. He was brought in by a scouting party, and was admitted to the Cavalry Corps Hospital. On the 25th of July he was sufficiently rational to give the above account to Surgeon Eulison, 9th J^etv York Cavalry. He was in a very depressed state at this time. His pidse was weak, and heat from forty to hfty pei- minute. He was indisposed to mental exertion ; but when aroused and interested was quite rational. He lingered until August If.th, 1863, the tendency to stupor increas- ing towards the close. The autopsy revealed a sabre-cut six inches long, which had raised an osseous flap, adherent at its base, from the left parietal, and cloven the right parietal, with great splintering of the vitreous plate. The sabre had pene- trated the dura mater on the left side, and on the right side the meninges were injured by the depressed inner table. The posterior lobes of both hemispheres of the brain were extensively disorganized. The specimen, with tho above history. Fig. 1.— Interior view of a segment ef tlie pane- was contributed by Surgeon W. H. Eulison, 9th New York Cavalry, since killed iff" ^Sect”™ a'*'m “ sabre-cut.— in battle. An external view of the specimen is presented in Figure 55, page 40, Circular No. 6, Surgeon General's Office, Washington, 1865. An internal view is given in the adjacent wood-cut. (Fig. 1.) Blood, A. N., Corporal, Co. C, 1st New Hampshire Cavalry. Sabre-fracture of the skull. Neivtown, Virginia, November 12th, 1864. Admitted to Field Hosjiital at Winchester, Virginia, on the same day. Inllammation of the brain siqiervened, and ho died, November 30th, 1864. Bradley, AleXjVXDER, Private, Co. E, 5th New York Cavalry, aged 23 years. Compound comminuted fracture of the occipital bone by a sabre. Hanover, Pennsylvania, June 30th, 1863. Admitted to Satterlee Hospital, Philadelphia, November 17th. Seventeen spiculm of bone were removed. Eeturned to duty November 28th, 1863. Browx, James W., Musician, Co. F, 13th Ohio Volunteers, 'aged 30 years. Sabre-fracture of the cranium. Atlanta, Ga., August 17th, 1864. Admitted to Hospital No. 1, Nashville, Tenn., August 27th. Discharged from service May 18th, 1865. Browx, S. L., Private, Co. G, 8th New York Cavalry. Sabre-cut of the scalp, with fracture of the left parietal bone. Gettysburg, July 1st, 1833. A segment of bone removed primarily. Insensibility lasted seven days. Admitted to hospital at York, Pennsylvania, July 19th. Eeturned to duty November 24th, 1863. CjVXFIELD, J. N., Corporal, Co. G, 15th New York Cavalry, aged 55 years. Fracture of the cranium, w'ith depression of the inner table by a blow from a sabre. Newmarket, Virginia. December 21st, 1864. Admitted to hospital at Frederick, Mary- land, December 23d. Discharged from service May 20th, 1865. Clark, Eichard, (colored,) officers' servant, aged 19 years. Sword fracture of tho left side of cranium. Iceport, Mississippi, February 2d, 1865. Admitted to Strader Hospital, Louisville, Kentucky, March 23d, from Field Hospital. Trans- ferred Itlarch 26, 1865, to New Albany, Indiana, Floating Hospital. Eeturned to duty June 27th, 1865. COLVix, JoiiX", Corporal, Co. B, IGth Pennsylvania Cavalry, being detached for s(!rvice with the provost marshal of the brigade, while in the performance of his duty, received, on January, 2d, 1864, a sabre-cut on the forehead. The right parietal bone was badly fractured near the sagittal and frontal -sutures. About one square inch of the bone being loose, was removed, together with several spicul®, and a sharp projection was removed by Hey’s saiv. The integuments were replticed over the opening in the skull by means of sutures, and the wound healed nearly by first intention. No unpleasant symptom, save one delirious night, occurred after the injury, and the man was returned from the Cavalry Corps Hospital to his regiment on .Janu- ary 28th, 1864. The operation was performed by Dr. George W. Colby, surgeon in chief of the brigade, and the case was reported by Assistant Sui’geon A. F. Herrmann. B , TnOMA.S, Private, Co. G, 5th Connecticut Volunteer.s, aged 48 years, was wounded at Chantilly, Virginia, on September 1st, 1862, by sev- eral sabre-blows over the right ear. He was taken to Washington, and ad- mitted to Douglas Hospital on September 5th. Pie was then suffering from partial hemiplegia, with mental hebetude. There was great tumefaction of the scalp. It was found that the right parietal was very extensively frac-' tured, (Fig. 2,) one fissurit running near the tem])oro-parietal suture, and others upwards and backwards from the ear. Near the parietal eminence there was a marked depression. It was determined to raise the depres.sed bone, and on September Gth, Acting Assistant Surgeon J. W. Williams applied the trephine, and, after removing a button and several fragments of bone, he excised a sharj) depressed angle by a Hey’s saw. It was ascer- 3 Fk;. 2 . — Vault of tho cranium, fihowin^ sovonil sabre outs of tho right iJurietal.— 235, Scot. I, A. M. M. 18 WOUNDS AND INJURIES OF THE HEAD tinned tliut the dura mater had been injured by the salire-cnts. After tlie elevation of the depressed fracture, the paralysis of the left side was relieved. The bead was shaven, and cold a])jilieations were iiorseveringly employed. For ten days subsequently the case iqipeared to jn-ogress favorably; but, on September 14tb, the patient began to be heavy and drowsy, and the following day there were clonic spasms of the left side and pleurosthotonos. At night the breathing was stertorous, the pnjiils were dilated, and the general symptoms of compression of the brain were very marked. Death took place on September- IGth, 1802. There was a targe coaguhim of extravasated blood under the scalp near the vertex, as though the man had fallen upon his head after being wounded. A jjiortcm. examination was made on September 17th. On removing the calvari.a, which was remarkable for its extreme thinness, it was found that the dura mater was jierfbrated beneath the intersection of the wounds, and that, for a sjiace of several inches, there was thickinung, with other evidences of inflammatory action. The arachnoid and j)ia mater were disintegrated in this vicinity, and a space comprising nearly half of the right cerebral hemis])here was occupied by an abscess. The calvaria was forwarded to the Army Medical Museum by Assistant Surgeon Warren Webster, U. S. Ai-my. It is rejiresented by FiG. 2, on the preceding page. D , J. M., Private, Co. M, 1st New Jersey Cavalry, aged 24 years, in a skirmish with the retreating enemy, near Burkesville, Virginia, on April (ith, 1885, received a sabre wound on the right side of the head. There was a cut tlu'ough the seal)) and pericranium three inches long, extending into the outer table of the skull and diploc, from the jiarietal eminence downwards and backwards. The wounded man was conveyed to the Cavalry Corps Ilosiiital, and thence to the Base Ilosjiital at City Point, and thence by water to Baltimore, where he was admitted to West’s Building Hospital, on May 11th, 1805. No re|)ort of his symptoms is given until his admission to the Baltimore hospital, when Acting Assistant Surgeon W. G. Knowles records that he suffered se- vere paroxysms of ))ain, re- curring frequently, and an- nounced by loud screams. In the intervals, he answered questions readily and ration- ally. In the evening of May 11th, he became composed and slejit tranquilly. He manifested signs of intelli- gence until within half an hour of his death, which oc- curred on May 12th, 1885. On May 13th, thirty-seven days after the reception of the injury, an antojisy was made by Acting Assistant Surgeon J. H. Butler. The incised fracture of the outer table was two and a half inches in length. At one point it penetrated through the diploe. Its edges were necrosed and suppurating. On removing the \ninlt of the cranium, a sjdinter of the internal talde, one and tliree-fourths of an inch in length and one-quarter of an inch wide, was found under the cut, depi'essed about two lines. This fragment was covered by a thick deposit of lymph, which filled the angles of the depression, and adhered to the dura mater. In this mem- brane there were two small perforations, due to idceration. These communicated with an abscess of the right hemisjdiere, filled with offensive pus. The dura mater was thickened and softened near the fracture, and discolored on its inner surface over a s])ace an inch in diameter. The specimen is preserved at the Army Medical ^luseum as a wet prejiaration, and is numbered 4208 of the Surgical Section. It is represented in the adjacent wood-cuts. (Fig. 3 and FiG. 4.) ric.. 3. — Sabre-cut of the right parietal.- Sect. 1, A. 51. 51. -Spec. 420G, rio- ‘1. — latcriur view of the furogohig specnneii. Dunn, Geougio, Corporal, Co. E, 7f)th New York Volunteers. Fracture of the left side of the front.al hone, near the coronal suture, by a sabre. There was a depression of both tables of the skull one inch in extent. Admitted to Carver Hospital, Washington, November 30th, 1832. Deserted March 21st, 1863. Englekee, Wir,ElA5l, Private, Co. B, 54th Kentucky Volunteers, aged 33 years. Three sabre wounds of the occipital region, and one of the left superciliary ridge. The latter fractured the outer plate of the frontal hone, and destroyed the vision of the left eye. There were also three cuts over the dorsum of the right hand. Saltville, Virginia, December 23d, 1864. Admitted to hospital at Lexington, Kentucky, January 8th, 1865, and discharged from service and pensioned. May 19th, 186.5. On March 4th, 1867, the examining surgeon of the I’ension Office rejiorted his disabilities as permanent. Fueybeut, Ai)A5I, Private, Co. B, 1st Maryland Cavalry, aged 34 j'ears. Compound comminuted fracture of the left parietal hone by a blow from a sabre. Brandy Station, Virginia, June 9th, 1863. Admitted to First Division Hosiiital, Annap- l, nine days after the receiRion of the injury, the man returned to duty, and that no subsecpient untoward symptoms a|ipeareil. ( I’llare’s name does not appear on the Pension List. In October, 1834, he was employed as a blacksmith at the Headquarters of the Army of the Potomac. Pl.STORIUS, William, Private, Co. E, bth Pennsylvania Cavalry, aged 39 years. Sabre-cut, with fracture and depression of the parietal bone. Petersburg, Virginia, June 9th, 1834. Admitted to hospital at Hamj)ton, Virginia, June 11th. Died June 18th, 1834, from compression of the brain. Reed, Jame.S T., Private, Co. C, 1st Y^’ermont Cavalry, aged 29 years, was wounded in a charge at Boousboro, Maryland, .Inly 6th, 1833, receiving two sabre-cuts, one on the head, the other on the left arm. The first was a slanting cut on the right parietal, which uncovered the dura mater, completely detaching a portion of the bone, the piece of the external table sliced off being two and a half inches in length and an inch and a quarter in breadth, while the portion including the diploe and internal table was much smaller. The integumental flap was not entirel}- separated from the scalp. The second cut involved the left elbow, and chipped off the olecranon process. The head was shaved on the field ; the piece of bone sliced off was se])a- rated from the flap, and the integument was replac(!d and secured by adhesive straps. Water dressings W(‘re aj)plied to the wound of the elbow, and the arm was placed in a sling. On July 16th, the patient was admitted to Hospital No. 1, Frederick, Maryland. The wound of the head hap. 140, 260.) In seven of these cases, the piece of bone sliced off was removed, and six of the patients recovered ; in four cases the Hap of bone was reapplied, and two ])atients recovered, and two died. M. H. Larrey (Relation Chiruryicale des Jzvenemens de Juillct, 1830, Paris, 1831, p. 35) cites the case of a locksmith, who, supposing himself to he followed by a large body of insurgents, rushed ui)on a squadron of grenadiers and received eight or ten sabre cuts on his head. There were several Haps ; one, including a large j)ortion of the j)arietal, fell over the right ear, exposing the dura mater over a space two inches long and an inch broad. Another, behind and above the left ear, contained a detached fragment of bone. 51. Magistel dressed the wounds, removing (uitirely the fragments of bone, and adjusting the flaps by sutures .and .adhesive strips. The patient was then jdaced in the Be.aujon Hospital, under the care of 5Iarjoliu .and Blandin. Complete recovery followed in about six weeks, and the man was presented to the Academy of 5Iedicine. II. 5Ieyer (lleiluny von Scliddelverletzungcn in LanycnhecFs Archiv., B. II, S. 91 uiid 101. Berlin, 1832) cites two cases of this nature; in one, the severed segment of bone w.as removed and the patient recoveu’ed; in the other, it was replaced, and the patient died of meningitis. The jiathological j)re]>aration from the latter case is specimen 1052, at the Museum of the University of Zurich. Baerwindt (Die Bchandluny von Kranhcn und Venoundeten untcr Zcltcn im Sommer 1866. W’urzburg, 1867, S. 93) relates two cases of rejilacement of the segment of bone, followed by necrosis, the ])atients recovering after the extraction of the exfoliation. Eavaton (Chiruryic d’Anncc, Paris, 1768, p. 549) also reports, in detail, two cases with a similar history. Kavoth und Vocke (Chiruryisrhe Klinil:, Berlin, 1852, S. 437) record tw'O e.xamples of recovery after removal of the osseous ttaj). B. Beck (Kricys-Chiruryische Erfahrunyen wdlirend des Feld- znyes, 1886, in Siiddeutschland. Freiburg, 1867, .S. 161) cites a very interesting case of recovery after the removal of a large segment of bone and the reapplication of the Hap of integument. On the other hand, Weiifer (Olscrvaiions Medko- Fracticce de Affectihus Capitis, Scaphusii, 1827, j). 34, Obs. 16) reports a very successful ease in which the osseous flap was reapplied. Another is cited by Baudens, (Clin, des Flaks d' Amies d Feu, I’aris, 1836, p. 122,) a complicated and very unjn-om- ising case at the outset. Theden (Neue Bemerlunyen und Erfahrunyen, 1782, Theil. I, S. 77) approves of replacing the bone. Chopart and Desault (Traite des Maladies Chirurykales et des Operations, Paris, 1796, p. 70) are of the same opinion, and C. .1. 51. Langenbeck (Nosoloyie und Thcrapie dcr Chiraryischen Krankheiten, Gottingen, 1830, S. 57) inclines in that direction. The authorities are about equally divided ; but the facts adduced seem to favor the ])ractice of removing the detachi'd or |)arti.ally detached segment of bone. ‘‘Additions to the Eighth Edition of Coopeds Dktionary of Frartkal Surgery, London, 1861, Vol. I, p. 885. INCISED FRACTUEES OF THE CRANIUM. 27 lliiiLy-one of flic forty-nine cases reported. Fifteen cases, of which two were fatal, would be included under the first head ; eight cases, four recoveries and four deaths, under the second ; six cases, three of which were fatal, under the third ; and two cases, a recovery and a death, under the fourth. In only one of the cases reported (R. Hall, p. 19), did the question arise of the treatment to be pursued in the event of a complete ablation of a portion of the skull, together with the integument, the connections of the flap with the head being entirely severed. In this case, the complications were so gra^m that the ques- tion was of little interest. It is not impossible that, if the portion of scalp shorn off, the fragment of bone being removed, were immediately replaced, and secured by stitches, reunio]! might ensue. But no example of such a plastic procedure has been recorded. On the contrary, authors advise that the dressing should be that of a wound with irreparable loss of substance, a simple dressing : for example, a compress spread with cerate and a retentive bandage. The utility of the trepan in incised fractures of the skull will be considered in the general discussion of the subject of trephining, at the close of this chapter. It will, therefore, be unnecessary to make any further observations on the treatment of incised fractures of the cranium ; since, unless it be decided that the symptoms demand operative interference, the treatment should be identical with that of incised scalp wounds. [See p. 15.) The returns confirm the observation of Thomson,^ renewed liy Dr. Macleod,^ on the remarkable rarity of hernia of the cerebral substance after sword, or compared with gun- shot wounds. This complication did not supervene in any of the cases reported, although in many of them the membranes of the brain were divided, wliile in several there was loss of brain tissue. In addition to those figured in previous pages of this section, the Army Medical Museum possesses eleven crania affording excellent illustrations of almost eAmry variety of incised fractures of the skull. As these specimens do not pertain to the Surgical His- tory of the American War, the reader must be referred to the Catalogue of the Museum for full descriptions of them.^ The three hundred and thirty-one cases of incised wounds of the scalp or cranium recorded in the earlier part of this section, comprise all of the sabre or sword cuts of the head entered on the registers of the Surgeon General’s Office that can be satisfactorily verified. Others are alluded to by medical officers, but so indefinitely that identification ‘ Report of Observations made in the Hriiish Military Ilospitals in licltjium after the battle of Waterloo, Ediiibiirgli, 1810, p. 50. Thomson cites a remarkable case of removal of the npjicr part of the occipital bone along with the dura mater, in which “a tendency to protrusion of the brain took jdace during an attack of inllammation ; a slight degree of stupor, with loss of memory, occurred ; but on the inflammatory state having been subdued the brain sank to its former level, tbe stupor went olf, and the memory returned.” Further on, he remarks: “we had frequent opportunities of seeing the upper and the lateral parts of the cerebrum exposed by sabre wounds; but, in no case, except that which I have mentioned, did any tendency to ju’otrusion of the brain present itself to our notice.” Notes on the Surgery of the War in the Crimea, by George 11. B. Macleod, M. D., London, 1858, p. 181. ® Specimens 970 and 971, Section I, are crania of Araucanlan Indians, killed by Chilian troops. No. 970 shows nine sabre-cuts, illustrating almost every variety of such injuries. It is figured at ]i. 39 of the Catalogue of the Surgical Section of Ai-my Medical Museum. No. 971 shows four cuts, which have sliced oft' a large portion of the left jiarietal. No. 5107 is a skull obtained at Waterloo, by Professor William Gibson, and exhibits a long perpendicular cut through the right parietal. Nos. 5249 and 5250 are crania of California Indians, killed near Fort Crook, and exhibit incised fractures of tbe vaidt of the skull by the tomahawk. No. 5529 is the skull of a Mataco Indian, showing two clean cross cuts on the vertex, and a deep oblique cleft in the left parietal; the inner table is divided without splintering; the wounds were inflicted by a very sharp sabre. Nos. 5530, 5532, 5534, 5537, are crania of California Indians, showing multiple incised fractures of the vault. No. 5544 is the skull of a Ponka squaw, showing a deep oblique section of the occipital by a sword; the inner table is cleaidy divided. 'J'he last nine Specimens will be fully described in tbe next edition of the Surgical Catalogue. 28 WOUNDS AND INJURIES OF THE HEAD has been impraclioable. Tims, for example, Surgeon D. S. McGuigan,^ 3d Iowa Cavalry, in liis report after the battle of Pea Ridge, refers to several sabre fractures of the skull, which do not appear upon the casualty lists, nor on any of the nominal or numerical returns of wounded : “The cavalry were pursued by Texan cavalry and mounted Indians, armed with a short and heavy sabre, made from large saw-mill files, and manufactured by their own mechanics. One blow with this rude weapon would crush through the integuments and bony walls of the cranium, into the brain.” * * “The wounds were mainly produced by rifle balls, and by the sword or knife already described. A number were killed by one stroke of this weapon, and I saw several who were severely wounded by it.” “The cavalry were wounded more frequently on tlie upper part of the trunk or the face, upon the head or upper extremities.” * “Here, too,” [at Leetown, Arkansas,] Surgeon McGuigan continues, “ I found several wounded by the sabre, two on the head. The integument only was divided in one case, and, in the other, the weapon had penetrated the calvarium, through the prominence of the left parietal bone, in a horizontal direction, and had divided the membranes, through which portions of the cerebral substance protruded. I also found three of our men with sabre-cuts upon the head and upper extremities, and several with minor injuries from the -same weapon. These wounded were carried to Cassville, Missouri.”" A number of the reports of medical directors and chief medical officers contain remarks on sabre wounds, that will be quoted in the general observations in the concluding volume of this work. The records of miscellaneous wounds and injuries include no cases of incised fractures of the skull, and but few of incised wounds of the scalp. These cases were commonly entered numerically, on the monthly report, under the rubric “incised wounds,” or “vulnus incisum,” and rarely by name. The total number of “incised wounds” reported during the four years of the war was twenty-one thousand four hundred and forty-four, with one hundred and ninety-six deaths; but it is impossible to determine how many of those were injuries of the head, since the seat of the wounds is not designated. The following cases of incised scalp wounds, which it is thought best to separate from the sword wounds, were reported by name: Hunt, John M., Private, Co. K, Cist Illinois Volunteers, aged 2.5 years, received an incised wound on the left side of ^ IlcpoH of the Operations of the Medical Department at the Battle of Pea llklrje, Arlcansas, on March Gth, 7th, and 8th, 1862. Bound MSS., S. G. O., Div. Surg. Roc., A. 125. ^ There is no regimental surgical register of the od Iowa Cavalry on file, at the Surgeon General’s Otilco, for the dates I’eferred to. No monthly sick reports for ^March and April, 1832, were received from the medical officer in charge of the regiment. There are no records on file from Cassville, Missouri, ])rior to February, 1865. The records of the military hospitals at Kolia, Springfield, Jefierson City, and St. Louis, Missouri, and of Keokuk and Davenport, Iowa, whither wounded were conveyed after the battle of I’ea Ridge, have been carefully searched and found not to contain, at the period mentioned, the name of a single wounded man from the 3d Iowa Cavalry. The “Death Registers” and the Casualty Lists of the Medical Director are equally silent respecting the killed and wounded of this regiment at the battle of Pea Ridge. The regimental olficeis of cavalry had peculiar difficulties in making prompt and accurate returns. When the commands were engaged in scouting and picket duty, they were dispersed in small detachments, and casualties took place of which the regimental surgeon was not cognizant; when they were engaged in expeditions in large columns, or raids, the marches were so rapid that there was little time for clerical work. * Similar weapons were carried by a large number of the Confederate sohliers captured at Roanoke Island, February 8th, 1832. These knives were styled by those who wore them : “ Yankee-killers.” They were from eighteen inches to twenty-four inches in length, and were made from scythe-blades or long files, sharpened to an edge, and set in wooden hilts. They were not used offensively at Roanoke Island, no disposition for hand-to-hand combat being manifested after the intrenched position was carried. The wood-cut is copied from two speciimms procureil at Roanok(f Island, by the compiler of this worlc. Fio, 8. — Knife or hang*- cr v/ern by Indian and other savages in the Confederate ser\’ice in the early part of the American \Var.* INCISED WOUNDS OF THE SCALP.' 29 fho licad by a kiiifi', at Miirfrcosboio, Tumiesseo, ISIarch 4tli, I860. lie was admitted to liosidtal 011 the same day, and returned to duty, cured, on April lltli, 1865. Jacksox, John, Freedman, was cut on the scalp by a knife, in an affray at Vicksburg, Mississippi, May 8th, 1884. lie was received into the Fieedman’s Hospital, whence he deserted on May l»ith, 1834. Lewis, John, Private, Co. K, 13th New York Artillery, aged 22 j'cars, received an incised wound of the scalp by a knife, on April 2Eth, 1865. He was admitted to Balfour Hospital, Portsmouth, Virginia, on the following day. He was discharged frem service on June 17th, 1865. !McEai!LAXD, John, Private, Co. I, 8th Ohio Cavalry, aged 25 year.s, received an incised wound of the scalj) by a blow from a knife, on January 7th, 1865. He was admitted to Island Hospital, Harper’s Ferry, Virginia, on January Cth, and returned to duty on March 6th, 1865. ScHUALA, Joseph, Private, Co. K, 12th New .Tersey Volunteers, aged 32 years, on May 7th, 1865, was struck by a comrade with a knife on the left side of the scalp, producing an incised wound. He was admitted to Lincoln Hospital, Washington, on June 24th, and was discharged from service on July 31st, 1865. Gheen, F. JL, Piivate, Co. H, 45th Kentucky Volunteers, aged 19 years, received an incised wound of the scalp over the superior angle of the parietal bone by a blow from an axe, on December 16th, 1864. He was admitted to hospital at Lexington, Kentucky, on December 21st, and returned to duty on April 1st, 1865, for muster-out of service with his regiment. L];niih:x, Daniel, Private, Co. F, 2Cth New York Volunteers, on November 3d, 1864, received a blow on the head from an axe, which produced an inciseol scalp wound. He ^vas admitted to Lincoln Hospital, Washington, on November 15th, and returned to dutj- on December 17th, 1864. S^iirii, Joel, Private, Co. I, 127th New York Volunteers, aged 21 years, was admitted to No. 1 Hospital, Beaufort South Carolina, on February 21st, 1835, with an incised wound of the scalp, produced by a blow from an axe. He was trans- ferred to hospital at Hilton Head on May 28th, and discharged from service on June 8th, 1865. Wa'ON, Feederick, Piivate, Co. G, 6th Wisconsin Volunteers, aged 17 years, received an incised wound over the left parietal and occipital regions, by a blow from an axe, on iMarch 5th, 1865. Ho was admitted to Lincoln Hospital, Washington, on April 4th, transferred thence to Mower Hospital, Philadelphia, on April 7th, and, on May 31st, he was received into the Harvey Hospital at Madison, Wisconsin. He was discharged from service on July 13th, 1835. In the lollowing examples of incised wounds of the scalp, the nature of the weapon by which the wound was inflicted is not reported : Arle, Hicnry, Private, Co. A, 107th IT. S. C. T., aged 27 years, was admitted to Crittenden Hospital, Louisville, Ken- tucky, on July 30th, 1865, with an incised wound of the scalp. He returned to duty on July 31st, 1865. Atlas, George, Private, Co. I, 32d North Carolina Degiment, aged 37 years, received an incised wound of the scalp at Spottsylvania, Virginia, May 10th, 1864. He was received into the Second Division Hosj)ital at Alexandria, on May 14th, and tran.sferred to Lincoln Hospital, Washington, on May 23th, whence he was sent to the Old Capitol Prison on June 1st, 1864. Boi.ton, .James, Private, Co. I, Cth Missouri Cavalry, was received into the Post Hospital, Schofield Barracks, St. Louis, ^lissouri, on September 28th, 1834, with an incised wound of the left side of the head. He returned to duty on October 3d, 1834. BowEits, J., Private, Co. H, 12th New York Cavalry, aged 34 yeiirs, was admitted to Foster Hospital, Newberne, North Carolina, on September 25th, 1863, with an incised scalp wound. He was rtJurned to duty December 9th, 1833. BuTTitREiitLD, S. H., Unassigned Substitute, aged 18 years, received an incised scalp-wound, and was admitted to hospital, at Pittsburgh, Pennsylvania, on May 20, 1865.’ He was discharged from service on May 27th, 1865. Dinne, Michael, Private, Co. B, 19th Pcnn.sylvania Cavalry, received an incised wound of the scalp on February 22d, 1834, at West Point, Mississippi. He was admitted to Washington Hospital, at Memphis, Tennessee, on February 27th, and returned to duty March 28th, 1834. Gaffney, J., Private, Co. B, 169th IJcw York Volunteers, aged 36 years, received an incised wound of the scalp at Fort Fisher, North Carolina, on January ICth, 1865. He was admitted to McDougal Hospital, Fort Schuyler, New York, on January 25th, and discharged from service on May 25th, 1865. Hall, A., Private, Co. A, 169th New York Volunteers, aged 51 years, receiv'cd an incised wound of the seal]i, and was admitted to McDoug.al Hospital, Fort Schuyler, New York, on June 6th, 1865. He was discharged from service on July 18th, 1865. IIoiVAitD, .John, Private, Co. B, 3d Khode Island Volunteers, aged 23 years, was admitted to Sickel Hospital, Alexan- dria, Viiginia, on May Cth, 1865, with an incised wound of the scalp. He returned to duty on May 18th, 1835. Johnson, F., Private, Co. F, 39th Ohio Volunteers, aged 19 years, was admitted to Crittenden Hospital, Louisville, Kentucky, on June 25th, 186.5, with an incised sc.alp wound. He was returned to duty on July 18th, 1865. Kella', J., Piivate, Co. 1), 2d Louisiana Cavalry, aged 30 years, received, in an afi'ray, a severe incised wound ( f the sc.-ilp. He was admitted to hospital at Baton Bouge, I.ouisiana, on May 2.5th, and returned to duty .Juno 13th, 1834. McCttACKEN, W. N., Private, Co. M, Cth Pennsylvania Heavy Artillery, aged 18 year.s, received an incised wound of the scalp on October 7th, 1834. He was admitted to 3d Division Hosiiital, Alexandria, Virginia, on October 10th, and returned to duty January 24th, 1865. 30 WOUNDS AND INJURIES OF THE HEAD, McUonalo, F., Riivato, Co. G, HEtli Keiitiiclcy Volimtoers, aged 29 years, was received into Main Street IIosi)ital, Covington. Kentucky, on April lltli, 1805, with an incised wound of the scalp, not received in action. He died on May 8th, 1805. Sattcrwhile, M., Private, Co. A, 44th North Carolina Regiment, received an incised wound of the scalp on June 2Gth, IStiJ. lie was admitted to Hospital No. 4, Richmond, Virginia, and furlonghed on July Gth, 1863. Stuuuk, John J., Private, Co. K, 178th New York Volunteers, aged 20 year.s, received an incised scalp-wound, and was admitted t(> Jefferson Barracks Hospital, St. Louis, Missouri, September 20th, 1834. He was returned to duty on September 27th, 1834. VAltliLIC, Henky, Private, Co. C, 22d Indiana Volunteers, aged 21 years, received an incised scalp-wound at Franklin, Tennessee, on November 30th, 18G4. He was admitted to Brown Hospital, Louisville, Kentucky, on June 21st, 18G5, and mustered out of service July 24th, 18G5. 'WiLEi.vtMS, A. M., Private, Co. G, 7th Pennsylvania Cavalry, was admitted to Cavalry Corps Hospital at Gallatin, Tennessee, on January 11th, 1835, with an incised wound of the scalp. He was transferred to Nashville on February 25tli, and discharged from service July 28th, 1835. Wyman, Joseph, Lieutenant, Co. FI, 9th Minnesota Volunteers, received an incised scali)-wound, and was .admitted to Post Hospital, St. Louis, Missouri, on May 19th, 18G4. He returned to duty on M.ay 30th, 18G4. Young, H. C., Ihivate, Co. F', 20th Kentucky Volunteers, aged 28 years, received an accidental incised scalp-wound, on FY'bruary 28th, 18G5. He was admitted to Brown Hospital, Louisville, Kentucky, on June 7th, 18G5. He was furloughed, and returned to duty on July 29th, 18G5. * Of these twenty-eight cases of incised wounds of the scalp by various weapons, one resulted fatally. Fifteen of the patients were returned to duty, one deserted, and eleven were mustered out, or paroled, or discharged, not for disability, but because their terms of enlistment had nearly expired.* Punctured Wounds of the Head. — The experience accpiired in the late war con- firms the common impression that punctured wounds of the integuments of the cranium, or perforations of the cranial bones by bayonet or lance, or sword thrusts, arc rare in modern times. On the infrequent occasions on which they are used offensively, these weapons are commonly directed against the chest or abdomen of an adversary. The majority of punctured wounds of the scalp or skull met with in military practice at the present day, result from accidents, or are inflicted in private quarrels, or by sentinels. Punctured Scalp Wounds. — Only eighteen cases of this nature arc recorded. Nine were inflicted by sentinels, or received in broils or attempts to desert. Nine were received in action. Armsteong, Ebenezer, Pi'ivate, Co. K, 8Gth Illinois Infantry. B.ayonet wound of the scalp. Kenesaw Mountain, Georgi.a, June 27th, 1864. Returned to duty. B.vll, Patisick, Private, Co. IT, 49th Pennsylvania Volunteers, aged 37 years. Bayonet wound of the scalp. Wilder- ness, Virginia, May 8th, 1864. Admitted to Emory Hospital, Washington, May 13th. Returned to duty M.ay IGth, 1864. Blake, Thomas, Privvn, E, 14th Illinois Cavalry, Nashville, Tennessee, February 9th, 1865. B. Busa, Government Employd, Washington, D. C., February 17th, 1864. Recruit J. Cain, Merrill’s Horse, St. Louis, Missouri, November 8th, 1864. Lieutenant H. D. Call, A, 76th New York Volunteers, Georgetown, D. C., January 9th, 1864. Private J. Cantrell, Schofield Hussars, St. Louis, Missouri, December 8th, 1883. Private W. C. Carroll, B, 4th Tennessee Volunteers, Louisville, Kentucky, March 30th, 1863. Private M. Casey, L, 1st Illinois Artillery, New Creek, West Virginia, November 10th, 1864. Private A. E. Chapman, C, 32d Massachusetts Volunteers, Washington, D. C., May 23d, 1865. Private J. Chase, G, 4th Michigan Cavalry, Nashville, Tennessee, March 6th, 1864. Deserted. Private J. Christie, A, 18th New York Cavalry, New Orleans, Louisiana, April 26th, 1865. Private IF. M. Clare, G, 20th Missouri Eegiment, Farmville, Va. Private H. W. Cochran, I, 17th Indiana Volunteers, Louisville, Kentucky, November 30th, 1864. Private B. Cofflety, G, 77th Pennsylvania Volunteers, Nashville, Tennessee, December 15th, 1864. Private J. Cox, A, 13th New York Cavalry, Washington, D. C., August 11th, 1884. Recruit J. E. Cranfield, G3d New York Volunteers, Alexandria, Virginia, May 8th, 1864. Private W. Daly, A, 16th United States Infantry, Nashville, Tennessee, December 18th, 1865. Private W. Danekas, E, 11th Illinois Volunteers, Memphis, Tennessee, April 6th, 1865. Private L. L. Davis, C, 15th New Jersey Volunteers, Washington, D. C., May 11th, 1864. John Dugan, Government Employd, Quartermaster’s Department, Nashville, Tennessee, November 28th, 1864. Private H. Dunham, I, 6th Missouri Volunteers, Nashville, Tennessee, December 9th, 1864. 52 WOUNDS AND INJURIES OF THE HEAD, Coi’poral S. Eplar, C, 2cl Minnesota Cavaliy, Fort Eidgely, Minnesota, April 13th, 1864. Private J. Erbay, A, 10th Michigan Volunteers, Knoxville, Tennessee, April 24th, 1864. Private A. C. Ewing, Q, 28th Kentucky Volunteers, Louisville, Kentucky, June 15th, 1865. Private C. Farnsworth, A, 3d Ohio Cavalry, New Albany, Indiana, April 10th, 1864. Private J. Fitzgerald, 21st Wisconsin Volunteers, Nashville, Tennessee, November 2d, 1884. Private M. Flaherty, C, 49th Missouri Volunteers, St. Louis, Missouri, November 17th, 1864. 1st Sergeant A. B. Francisco, F, 124th New York Volunteers, Chester, Pennsylvania, May 30th, 1864. Corporal G. Gamble, A, 27th Pennsylvania Volunteers, Nashville, Tennessee, May 13th, 1864. Private P. Gannon, K, 39th Massachusetts Volunteers, Boston, Massachusetts, May 9th, 1864. Sergeant J. N. Gilchrist, K, 5th Alabama Infantry, Eichmond, Virginia, June 4th, 1864. Corporal T. Gleason, E, 63d New York Volunteers, Nashville, Tennessee, September 7th, 1865. Private J. G. Gossman, B, 176th Ohio Volunteers, Nashville, Tennessee, August 2d, 1864. Private A. Grant, H, 59th Indiana Volunteers, Tullahoma, Tennessee, September 1st, 1864. Private J. B. Griffith, I, 95th Pennsylvania Volunteers, Washington, D. C., May 14th, 1864. Sergeant C. B. Hadley, B, 56th Massachusetts Volunteers, Boston, Massachusetts, April 21st, 1864. Private W. Uatsell, B, 6th Kentucky Eegiment, Nashville, Tennessee, September 24th, 1863. Private H. Henning, E, 8th Iowa Cavalry, in action, Tuscaloosa, Alabama, April 3d, 1865. Private J. M. Heevey, A, 5Cth Georgia Infantry, Nashville, Tennessee, February 16th, 1864. Private J. Hickey, D, 23d Indiana Volunteers, Louisville, Kentucky, June 25th, 1865. Private E. B. Hieronymus, B, 7th Missouri State Militia Cavalry, St. Louis, Missouri, March 30th, 1865. Private M. Higgins, L, 2d Massachusetts Artillery, Portsmouth, Virginia, July 1st, 1865. Private F. Howe, G, 6th Vermont Volunteers, January 6th, 1865. Private J. Hudson, C, 2d United States Infantry, Elmira, New York, January 7th, 1865. Private J. Jenks, F, 51st New York Volunteers, Alexandria, Virginia, April 23d, 1864. Private J. James, Unassigned Substitute, Elmira, New York, May 7th, 1865. Sergeant W. A. Johnson, A, 15th Indiana Battery, Washington, D. C., February 17th, 1865. Private J. Kanally, K, 35th Indiana Volunteers, Louisville, Kentucky, February 22d, 1864. Erysipelas. Private D. Kelly, K, 73d Pennsylvania Volunteers, Philadelphia, Pennsylvania, July 8th, 1863. Deserted. Private E. A. Knapp, I, 89th Illinois Volunteers, Nashville, Tennessee, May 29th, 1864. A. Kruse, Contract Nurse, Washington, D. C., May 15th, 1864. Corporal T. Langley, E, 10th United States Colored Troops, Portsmouth, Virginia, May 27th, 1865. Private A. J. Little, H, 5th Missouri State Militia Cavalry, Eolla, Missouri, July 4th, 1864. Private J. S. Lockwood, A, 17th Connecticut Volunteers, St. Augustine, Florida, June 11th, 1864. Private J. McAldee, 2d Indiana Battery, Nashville, Tennessee, February 16th, 1865. Private B. McCarty, B, 21st Connecticut Volunteers, Portsmouth, Virginia, May 5th, 1865. Private E. McCarty, B, 40th Missouri Volunteers, St. Louis, Missouri, November 0th, 1864. Private C. McDonald, C, 19th Massachusetts Volunteers, in action, Wilderness, Virginia, May 6th, 1864. Private N. SIcEnroe, F, 2d New York Volunteers, Newark, New Jersey, June 6th, 1834. Private P. McGevi, B, 10th Tennessee Volunteers, Nashville, Tennessee, November 0th, 1864. Private M. McKenney, I, 1st United States Artillery, Gettysburg, Pennsylvania, July 3, 1863. Piivate C. McMahon, I, 5th Missouri State Militia Cavalry, St. Louis, Missouri, January 1st, 1865. Private P. Mahon, F, 20th Connecticut Volunteers, Aquia Creek, Virginia, May 4th, 1863. Private F. Man-ais, 7th Massachusetts Battery, New Orleans, Louisiana, March 18th, 1864. Private J. Marity, G, 1st Michigan Engineers, Louisville, Kentucky, March 15th, 1864. Private M. Miller, C, 2d Ohio Heavy Artillery, Bowling Green, Kentucky, October 22d, 1863. Private 5V. Missor, G, 87th Illinois Volunteers, St. Louis, ^Missouri, December 18th, 1862. Deserted. Private S. W. Morgan, G, 1st Indiana ArtOlery, New Orleans, Louisiana, January 8th, 1864. Private W. J. Mowry, K, 11th Illinois Cavalry, Vicksburg, Mississippi, February 24th, 1804. Sergeant J. Murphy, D, 2d Maryland Cavalry, Annapolis, Maryland, August 27th, 1863. Private jSI. Murray, C, 6th New York Heavy Artillery, Washington, D. C., August 16th, 1864. Private J. F. Neal, F, 55th Kentucky Volunteers, Louisville, Kentucky, May 26th, 1865. Private T. Newell, D, 0th Kentucky Cavalry, Louisville, Kentucky, March 18th, 1804. Private J. O. Barker, H, 9th United States Colored Troops, Portsmouth, Virginia, May 27th, 1865. Private J. O’Hara, D, 2d Massachusetts Heavy Artillery, Boston, Massachusetts, September 12th, 1865. Private 7F. Palmer, B, 26th Virginia Infantry, June 17th, 1864. Sergeant A. M. Parmenter, E, 29th Michigan Volunteers, Louisville, Kentucky, October 11th, 1864. W. Par-ker, Substitute, 10th Kentucky Volunteers, Nashville, Tennessee, December 9th, 1804. Deserted. Orderly Sergeant T. Pepper, United States Army, Covington Kentucky, June 18th, 1865. Private W. H. Peiry, K, 6th Illinois Volunteers, Nashville, Tennessee, July 2Sth, 1885. Private J. M. Pierce, H, 6th Indiana Volunteers, Chattanooga, Tennessee, November 25th, 1863. Private L. E. Porter, H, 109th New York Volunteers, Baltimore, Maryland, August 23d, 1864. Private J. KUey, D, 4th United States Infantry, New York, August 30th, 1865. Private J. Ritchey, H, 18th Kentucky Infantry, Murfreesboro, Tennessee, September 26th, 1863. Private M. Rodgers, D, 14th United States Infantry, Elmira, New York, January 7th, 1865. Deserted. A. Eosa, Blacksmith, L, 1st Illinois Artillery,' Vicksburg, Mississippi, ]\Iay 29th, 1864. Private R. Scerter, G, 30th Indiana Volunteers, Nashville, Tennessee, May 19th, 1884. FEOM UNSPECIFIED CAUSES OTHER THAN GUNSHOT. 53 Private J. Scribner, D, lltli Missouri Cavalry, St. Louis, Missouri, December 28tlt, 1864. Corporal L. Seiper, E, 4()th Missouri Volunteers, St. Louis, Missouri, November 7tb, 1884. Private D. Smallwood, C, 15th United States Colored Troops, Nashville, Tennessee, August 19th, 1865. First Lieutenant A. Smith, D, 51st New York Volunteers, Alexandria, Virginia, May 18th, 1865. Recruit C. Smith, 14th New York Artillei-y, Elmira, New York, December 29th, 1863. Private D.' Smith, D, 1st Wisconsin Cavalry, Nashville, Tennessee, March 9th, 1864. Private H. Smith, A, 68th New York Volunteers, Nashville, Tennessee, December 16th, 1864. Private 1. Smith, D, 31st Maine Volunteers, Boston, Massachusetts, April 18th, 1864. Private J. Smith, A, 9th New York Volunteers, New York, July 20th, 1863. Deserted. Private J. Smith, B, 18th New York Cavalry, Washington, D. C., F(!bruary 14th, 1864. Deserted. Private J. Smith, C, 10th Tennessee Mounted Infantry, Nashville, Tennessee, May 4th, 1864. Private W. A. Smith, F, 1st Delaware Volutiteers, Wilderness, Virginia, May 5th, 1864. Private J. Spencer, A, 179th Ohio Volunteers, Louisville, Kentucky, October 6th, 1864. Private T. Sullivan, F, 52d Illinois Volunteers, Louisville, Kentucky, June 21st, 1865. Corporal J. Suter, E, 7th Veteran Reserve Corps, Louisville, Kentucky, July 19th, 1864. Private J. Sutter, K, 1st Michigan Cavalry, Washington, D. C., March 2d, 1864. Private IF. C. Swanson, K, 12th North Carolina Infantry, Richmond, Virginia, April 28th, 1863. Private E. Sweat, F, 93d New Y’’ork Volunteers, Wilderness, Virginia, M.ay 5th, 1864. Private E. Taylor, F, 3d Ohio Cavalry, Nashville, Tennessee, June 8th, 1864. Private D. 7V. Vicks, C, 50th Georgia Regiment, Richmond, Virginia, June 5th, 1863. Private W. Visser, G, 82d Illinois Volunteers, Ballesville, Illinois, December 18th, 1882. Deserted. Private J. Walcott, I, 50th Ohio Volunteers, Baltimore, Maryland, February 4th, 1865. Corporal P. Walton, I, 111th Pennsylvania Volunteers, Savannah, Georgia, February 1st, 1865. Corporal C. Williams, M, 2d Massachusetts Cavalry, Winchester, Virginia, January 23d, 1865. Private T. Wilson, ]\I, 3d United States Cav.alry, Little Rock, Ai’kansas, February 19th, 1866. Private H. Wolf, B, 9th New Y’’ork Cavalry, Washington, D. C., June 20th, 1865. Private G. B. Young, B, 04th United Slates Colored Ti’oops, Vicksburg, Mississippi, July 31st, 1805. \ The following are examples of graver injuries belonging to the foregoing category : Case. — Private Frederick Burling, Co. D, 23d New York Volunteers, aged 21 years, received a severe injury of the head, at Upton’s Hill, Virginia. Deafness and partial paralysis ensued, and he was discharged from service on March 1st, 1862. Case. — Private O. B. Cook, Co. II, 14th Vermont Volunteers, received a severe injury of the head, at Fairfax Court House, Virginia, January 4th, 1883, and was discharged for disability, rated at one-half, on March 24th, 1863. Surgeon A. T. Woodward, 14th Vennont Volunteers, records the case. Case. — Private Milton Crowell, Co. B, 84th Illinois Volunteers, received a contused wound of the head, in May, 1863, and was admitted to Gayoso Hospital, Memphis, Tennessee, June 1st. Cerebral complications arose, and he died on June 5th, 1883. Surgeon D. W. Hartshom, U. S. V., records the case. Case. — Private Edward Garnett, Co. B, 5th Ohio Volunteers, at Camp Banks, in the spring of 1863, received an injury of the head, which resulted in impairment of the mental faculties. Complete loss of memory was a remarkable feature of the case. The patient was discharged for total disability by order of Surgeon R. O. Abbott, U. S. Army, the Medical Director of the Department of Washington, Mai’cli 3d, 1863. The case is recorded by Surgeon J. H. Wythes, U. S. V. Case. — W. F. Kirkland, a recruit of the 16th New Y’’ork Cavalry, aged 43 years, received a lacerated wound of the scalp in the fi-ontal region. May 4th, 1864, and was admitted to Camden Street Hospital, Baltimore. Erysipelas of the scalp supervened, and was followed by meningeal inflammation. The patient died on IMay 13th, 1864. Surgeon Z. E. Bliss, U. S. V., records the case. Case. — Private Thomas Morrissey, Co. A, 2d Vermont Volunteers, aged 26 years, was admitted to Lincoln Hospital, Washington, April, 1833, under the charge of Sni-geon H. Bryant, U. S. Volunteers, on account of a contusion of the head. Symptoms of arachnitis were manifested; but the patient recovered partially, w.as transferred to a convalescent camp near Alexandria, on March 10th. He was discharged from service on JIarch 20th, 1883. His mental faculties were much impaired. His disability w’as rated at two-thirds. Surgeon S. B. Hunt, U. S. V., records the case. Case. — Sergeant Richard M. Porter, 37th Massachusetts Volunteers, aged 28 years, received a contusion of the seal]), in July, 1884. He wms admitted into Augur Hospital, and, on August 2d, he was transferred to the 3d Division Hos{)ital, at Alexandria, with symptoms of incipient cerebritis. He died, August 28th, 1864. Surgeon E. Bentley, U. S. V., records the case. Case. — Private Thomas Solomon, Co. F, 2d Louisiana Mounted Infantry, aged 50 years, received, in camp, near Green- ville, Louisiana, June 18th, 1864, a contused wound of the scalp. On' Juno 20th, he was transferred to University Hospital, New Orleans, and on December 21st, 1864, he was transferred to the Veteran Reserve Corps. The following arc abstracts of cases of simple or compound fractures of the skull, produced by causes not specified, save that it is statctl that they were not inflicted by gunshot : 54 WOUNDS AND INJURIES OF THE HEAD Case. — Private Robert Bibb, Co. E, 4tli Virginia Regiment, was admitted, March 31st, 1864, into the hospital at the Old Capitol Prison, Washington, with a simple fracture of the skull. He died, April 6th, 1866. Case. — Private James Burns, Co. B, S9th Massachusetts Volunteers, aged 57 years, was admitted to Stanton Hospital, Washington, on July 14th, 1863, with a fracture of the cranium. He was transferred to Sattcrlee Hospital, Philadelphia, on May 10th, 1864, and returned to duty October 18fh, 1864. Siu'geon I. I. Hayes, U. S. V., records the case. Case. — Private Peter Cahill, Co. C, 79th New York Volunteers, aged 19 years, received an accidental compound fracture of the external table of the frontal hone, June 14th, 1665, while serving on the Provost Marshal’s Guard. He was admitted to Sickel Hospital, Alexandria, on June 14th, and discharged from service well, on July 4th, 1865. Surgeon E. Bentley, U. S. V., records the case. Case. — Private W. H. Christ, Co. I, 126th Ohio Volunteers, aged 24 years, was admitted to the base hospital, at City Point, Virginia, with a lacerated wound of the scalp, and fracture of the skull, April 24th, 1865. He was transferred to Patterson Park, Baltimore, May 18th, to Hick’s Hospital, convalescent, June 8th, and discharged from service, well, June 17th, 1865. Surgeon Thomas Sim, U. S. V., records the case. Case. — Private Peter Clofat, Co. E, 2d Louisiana Regiment, was sent to the St. James Hospital, New Orleans, on Jlay 10th, 1863, by the Provost Marshal, with fracture of the skull. He died on the following day. Assistant Surgeon J. Homans, U. S. A., records the case. Case. — The body of private John C , Co. K, 2d U. S. Infantry, aged 30 years, was brought into hospital, at Fort Columbus, New York Harbor, on January 21st, 1865. It was found that life was entirely extinct. There was a contused and lacerated wound, three inches in length, behind the left ear, and a depressed fracture on the left side of the occipital. No clue whatever could he obtained as to the nature of the weapon by which the injury was inflicted; nor, indeed, could it he accurately determined whether it was due to a blow, or to a fall. At the autopsy, it was found that the medulla oblongata was torn away almost completely from the pons Varolii. There was great intracranial extravasation of blood, and a fracture extending across the occipital and temporal bones to the left side of the foramen magnum. A fissure proceeded also through the right condyloid foramen into the mastoid jtrocess of the right temporal. Assistant Surgeon P. S. Conner, U. S. Army, fonvarded to the Army Medical Museum the notes of the case, and a section of the skull, which is represented in the accompanying wood-cut, (FiG. 18.) Fig. 18. — Section of base of cranium show- ing depressed fracture. — Spec. 4351, Sect. I, A. M. M. Case. — Captain J. B. Forcum, Co. H, 4th Noi’th C.arolina Infantry, received, at Gettysburg, July 1st, 1863, a simple fracture of the cranium. Ho was admitted to Hospital No. 4, at Richmond, Virginia, and recovered, and was furloughed, August 3d, 1863. Surgeon J. B. Read, C. S. A., records the case. Case. — Bugler Morris Houlahan, Co. G, 5th U. S. Cavalry, was admitted to the Seminary Hospital, Georgetown, December 11th, 1862, with a fracture of the skull, and died the same day. Acting Assistant Surgeon Landon Wells records the case. Case. — Private John Hines, Co. D, 3d Michigan Volunteers, aged 39 years, received a fracture of the right side of the frontal bone, on October 28th, 1834. He was treated at Huntsville, Alabama; Nashville, Tennessee; Louisville, Kentucky; and recovered, and was discharged from service, June 9th, 1865. Surgeon B. B. Breed, U. S. V., records the case. Case. — Sergeant R. TV. Jones, 1st Virginia Artillery, was admitted to Chimborazo Hospital, Richmond, Virginia, on November 17th, 1863, with a fracture of the skull. He recovered, and returned to duty, December 13th, 1863. Surgeon E. S. Smith, C. S. A., records the case. Case. — Private Michael McNulty, Co. E, 77th Pennsylvania Volunteers, aged 24 years, received a simple fracture of the frontal bone, December 10th, 1864, at Nashville, Tennessee. He was transferred to Louisville, thence to Camp Dennison, Ohio, and recovered, and was returned to duty, January 7th, 1865. Surgeon J. E. Herbst, U. S. V., records the case. Case. — Private Andrew Mader, Co. L, 3d Pennsylvania Artillery, received a simple fracture of the light parietal, December 13th, 1864. The line of fracture passed across the middle meningeal artery, which was ruptured, and gave rise to a large extravasation of blood. He was admitted to Balfour Hospital, Portsmouth, Virginia, with every symptom of compression of the brain. He died, December 16th, 1864. An autopsy revealed a large coagulum over the right hemisphere. Assistant Surgeon J. H. Frantz, U. S. A., records the case. Case. — Private George W. Morey, Co. E, 10th Michigan Volunteers, aged 23 years, received a contused wound on the left side of the head, at Tunnel Hill, Georgia, in April, 1834. The existence of fracture Avas suspected, but not clearly diagnos- ticated. The patient was treated at Hospital No. 19, Nashville, Tennessee, at Louisville, Kentucky, and at St. Mary’s Hospital, Detroit, Michigan. He had frequent epileptic convulsions, and died in one of the paroxysms. May 25, 1864. Case. — Sergeant John Miller, Co. I, 2d Illinois Artillery, Avas admitted to Indianapolis Hospital, in September, 1832, Avith fracture of the skull. He died, September 17th, 1882. Surgeon J. S. Bobbs, Brigade Surgeon, U. S. V., I'ecords the case. Case. — Private Daniel W. Nash, Co. F, 31st Ohio Volunteers, received a simple fracture of the skull, in February, 1833. He Avas admitted to Hospital No. 10, at Louisville, Kentucky, and Avas discharged from service, February 28tb, 1863. Acting Assistant Surgeon E. O. BroAvn records the case. FEACTUEES FEOM UNSPECIFIED CAUSES. 55 Case.— Teamster Wasliiiigtoii Odell, Co. I, DStli Illinois Volniiteors, received aii injury of tlie skull in 1863. Ho was admitted to Camp Dennison Hospital, Ohio, and was discharged from service on August 12th, 1863. Surgeon H. C. McAllister, 98th Illinois Volunteers, records the case. Case.— Private Stephen E. Potts, New York Marine Artillery, wtis admitted to Foster Hospital, Newberne, North Carolina, August 23d, 1862, with a simple fracture of the skull. He recovered, and was discharged from service, December 13th, 1833. Case.— Private Dennis Quinn, Co. F, 11th Veteran Eeserve Corps, received, in September, 1864, a simple fracture of the frontal bone, with a slight depression. He was admitted to Judiciary Square Hospital, Washington, on September 24th, and recovered, and returned to duty on October 8th, 1884. Assistant Surgeon P. C. Davis, U. S. A., records the case. Case.— Private William Eussell, 26th New York Battery, was admitted to the St. James’ Hospital, New Orleans, Louisiana, on March 11th, 18G3, with a simple fracture of the skull. He recovered, and was discharged from service, on May 11th, 1863. Assistant Surgeon John Homans, U. S. A., records the case. Case. — Private J. C. E , Pennsylvania Artillery, aged 22 years, was admitted, on September oOth, 18o4, to Jarvis Hospital, Baltimore, Maryland, in an inebriated condition, with a contusion of the left side of the face, and a small contused wound over the left malar bone. No history of the cause or circumstances attending his accident could be ascertained. Cold applications were made to the head, and he was kept quiet in bed. No symptoms of grave cerebral miscfiief appeared until the evening of October 5th, ^vhen he became noisily delirious. He became comatose, and died the following morning. Scctio cada- veris twenty-four hours after death. There was ecehymosis on the left side of the face ; the left ramus of the lower jaw bore traces of an old gunshot fracture. There was also a gunshot fracture involving the right shoulder. On removing the scalp, dark blood oozed from the ruptured veins, and on removing the skull-cap and cere- brum, a clot of blood of from one and a half to two ounces was found between the frontal bone and dura mater on the left side, adhering to the membrane. It must, necessarily, have compressed greatly the anterior lobe of the left hemisphere. Thei’e was also a clot at the posterior surface of the posterior lobe of the i-ight hemisjihere The cerebral substance was softened at this point. There was eflusion of serum over the pons Varolii and in the third and fourth ventricles. The arachnoid membrane was considerably separated from the sulci by effusion into the subarachnoid cavity. The veins of the pia mater were everywhere turgid. The fracture commenced on the outer part of the left superciliary ridge, and passed across the left orbital plate of the frontal, fissuring the ethmoid, and the body of the sphenoid. The sphenoidal fissure on the left side was enlarged as though by absorption from without. Acting Assistant Surgeon B. B. Miles contributed the specimen, (Fig. 19,) with the notes in the case. Case. — Private Frederick Seltzer, 5th U. S. Artillery, was admitted to the Seminary Hospital, Georgetown, D. C., J anuary 8th, 1832, with a fracture of the skull. Ho died on January 12th, 1862. Surgeon Joseph E. Smith, U. S. A., records the case. Case.— Private J. M. Sharp, Co. F., 45th North Carolina Eegiinent, received a simple fracture of the zygoma of the right temporal, without injury to the cranial cavity. Ho was admitted to the Farmville Hospital, Virginia, on J une 2d, 1864. He recovered, and was fiuloughed on August 9th, 1834. Surgeon H. D. Taliaferro, C. S. A., records the case. Case. — Private Adolphus Seymour, Co. F, 1st New York Cavalry, aged 21 years, received a simple fracture of the right side of the frontal bone, at Now Market, Virgini.a, May 15th, 1864. Ho was transferred in June to Frederick, Maryland, and in October to Annapolis Junction, and thence to Satterleo Hospital, Philadelphia, .and finally to Turner’s Lane Hospital, whence ho was discharged on M.arch 16tli, 1835, on account of confirmed epilepsy. C.\SE. — Private Frederick St.apley, Co. E, 92d Illinois Volunteers, was .admitted to Hospital No. 19, Nashville, Tennessee, on June 4th, 1833, on account of a simple fracture of the skull, according to the hospital register. If the diagnosis was correct, the case was unusually successful, since the patient returned to duty on June 18th, 1833. Surgeon .John W. Foye, U. S. V., records the case. Case. — Private Frank Treber, Co. D, 10th Tennessee Volunteers, aged 38 years, was admitted to Hospital No. 19, Nash- ville, Tennessee, on March 21st, 1835, with a simple depressed fracture of the os frontis. He w.as transferred to Cund)erland Hospital on April 20th, .and returned to duty, well, on April 29th, 1835. Surgeon B. Cloak, U. S. V., records the case. Removal of Feagments. — In the following cases of fracture of the skull, from falls or blows, depressed fragments of bone were removed by the forceps, saw, or elevator: Case. — Seaman Henry Black, of the United States Transport S; E. Spalding, fell from the spar deck into the hold, on June 20th, 1833, a distance of twenty-four feet, striking on the vertex of the skull. A large scalp wound, four inches in length, with fracture of both tables of the skull, with depression, having a diameter of two inches, was ])roducod. On his admission to the military hospital at Beaufort, North C.arolina, the man was i)ale, his pulse imi)erceptible, .and he lay groaning occasionally, his lower limbs moving sjtasmodically. The trephine was ap|)lied, but the d('pressed portion of bone could not be raised by the elevator. A portion of the fractured skull was then removed by Hey’s saw ; after which, the remiiiuing portion was raised to its normal position by the elevator, .and the periosteum, which had been carefully ])reserved, was brought back over the solution Fig. 19. — Fracture of the orbital pl.ate of the frontal, the ethmoid, and sphenoid. — Spec. 3440, Sect. I, A. M. M. 56 WOUNDS AND INJURIES OF THE HEAD of continuity of tlie bone. Tlie wound %vas then dressed with cold water. The after treatment was of stimulant and tonic description, with careful attention to the bowels, and occasional opiates. At the date of the report, fifteen days after the oiieration, the' patient was walking about the ward. The wound of the scali) was united, and the small portion over tlie trephined part was healing by granulation. The case appears on the monthly report of Beaufort Hosjiital, North Carolina, signed by Surgeon F. S. Ainsworth, U. S. V. 0^vsE. — Private Edward Connors, Co. A, 9th Illinois Cavalry, aged 22 years, received in a street fight, March 22d, 1864, a blow from a stone, which struck .the left side of the forehead. He was admitted into the Lawson Hospital at St. Louis, Illissouri, on the same day. There was an external wound throe inches in length, a depressed fracture involving both tables of the skull. Several small sjiiculai of bone were removed, and the depression of the inner table was raised by an elevator. A piece of the broken outer table was missing, having, apparently, been torn off at the time of the injury. A saline purgative was administered and low diet was prescribed, with cold water applications to his head. His general condition at this time was good : the pulse was natural, the pupils were sensible to light and normal in movement, and his intellect was perfectly clear. He continued thus until the night of the 23d, when symptoms of concussion and compression of the brain were manifested ; the symptoms of compression, perhaps, pi-edominating. On the following day, there was evidently compression, as indicated by the stertorous breathing and insensibility, dilated pupils and slow pulse. Death took place at midnight on March 24th, 1864. An autopsy was made on the following day. The external table of the frontal bone showed the loss of a fragment of the size of a quarter of a dollar. A fissure extended backwards an inch and a half into the left parietal. There was a stellate fracture of the inner table, but no depression. At the seat of injury there was no extravasation of blood. The brain substance around this point was softened, but to an inconsiderable degree. The specimen was preserved, but was not forwarded to the Army Medical Museum. The case was reported by Surgeon C. T. Alexander, U. S. A., in charge of Lawson Hospital. Case. — Private Miles P. Hatch, Co. H, 161st New York Volunteers, aged 22 years, was admitted, on January 12th, 1865, to St. Louis Hospital, New Orleans, Louisiana, with twenty other wounded men, injured on the occasion of the collision between the United States transport J. H. Dickey, and John Pain, on the Mississippi River, fifteen miles below Vicksburg, on January 9th, 1865. Private Hatch W’as found to be still laboring under the efl'ects of concussion of the brain. He had received a violent blow, causing a wound of the scalp and fracture of the skull. Symptoms of injury to the brain persisting, the wound in the scalp was enlarged, and the fracture was exposed, and a fragment of depressed bone was removed. The case terminated fatally on January 14th, 1865. This imperfect account is derived from the monthly report of the 161st New York Volunteers, for January, 1835, and from tlie hospital register, signed by Surgeon A. MciSIahon, U. S. V. Case. — Private Jonathan Leet, Co. M, 22d Pennsylvania Cavalry, aged 18 yeai-s, received, on April 4th, 1835, a com- minuted fracture of the ci anium, by a blow from a glass bottle. He was admitted to hospital, at Oumberland, Maryland, on May 14th, from his regiment. Fragments of bone were removed on the following day. He was discharged from service on August 15th, 1865. Surgeon J. B. Lewis, U. S. V., records the case. Case. — Private Conrad Murphy, Co. E, 17th Kentucky Volunteers, was confined for misconduct in the guard-house, on February 15th, 1863. He was insubordinate, and the sentinel struck him on the head with the butt of a musket, with such violence as to fracture the frontal bone, klurphy was taken to the Post Hospital, at Clarksville, Tennessee, under the charge of Surgeon A. B. Patterson, 102d Ohio Volunteers. Stertorous breathing, dilated pupils, oppressed pulse, and stupor, indicated compression of the brain. An incision was made at the seat of injury, and the depressed bone was elevated, and detached spiculse were removed, but the grave sjTnptoms were not modified, and death took place on February 16th, 1863. At the autopsy, made by Assistant Surgeon S. Hubbard, 17th Kentucky Volunteers, it was found that there had been an extensive extravasation of blood uj)on the brain. Case. — Private , 149th New York Volunteers, received at Stevenson, Alabama, January 23th, 1864, a heavy blow from a glass bottle, in a private quarrel, in the camp of the Second Division, Twentieth Army Corps. He was taken to the regimental hospital, and Surgeon J. V. Kendall, 149th New York Volunteers, ascertained that there was a fracture of the frontal bone over the right frontal sinus, with depression of the vitreous table. The patient had I’epeated convulsions and in the intervals was partially comatose. Surgeon Kendall extended the wound in the integument so as to freely expose the bone, and removed four fragments of bone, and also raised a depressed portion of the inner plate, which was not detached. The scalp was then brought together by sutures, and cold water dressings were applied. The patient was rejiorted as doing well in Februaiy, the symptoms of compression being entirely relieved, but it has been imj)racticable to leai'ii the ultimate result of the case. The fragments of bone removed are represented in the adjoining wood-cut, (FiG. 20,) and comprise about half a square inch of the inner table, and a somewhat larger portion of the external table. Fig. 20. — Four frag-inents removed from the right side of the frontal bone, fractured by a blow from a bottle ; natural size. 2210, Sect. I, A. JI. M. Case. — PriAate Charles V. Orton, Co. L, 1st Tennessee Cavalry, in an engagement at Shoal Creek, Alabama, October 19th, 1864, received a wound in the neck from a musket ball, which lodged under the sterno-cleido-mastoid muscle, and also a blow, apparently from the butt of a musket, or stone, which produced a compound fracture of the frontal bone. The regimental surgeon. Dr. W. F. Green, reports that several fragments of bone were removed from the forehead, and the signs of compression of the brain being thereby relieved, the patient was sent, by way of Pulaski, to Nashville, Tennessee, and was admitted to Hospital No. 14, on November 23d. He was subsequently sent to the West End Hospital, at Cincinnati, Ohio, and was discharged from service on May 2d, 1865, for disability rated at three-fourths. He was allowed a pension of six dollars per month from this date, and Commissioner H. Van Aernam states that he drew his pension on March 4th, 1889; but that the particulars of his condition at that time were not reported. REMOVAL OF FRAGMENTS AND TREPHINING. 57 Fig. 21. — Segment of right parietal, showing a fracture from a blow from a spade. — Spec. 712, Sect. I, A. M. M. Case.— At Antictam, Maryland, September 17tb, 1862, a soldier, employed in entrenching, struck another, on the left side of his head, with the edge of a spade. The wounded man fell, badly stunned, and, on examination, it was found that the blow had produced a depressed frac- ture of the left parietal bone. The patient was conveyed to the Smoketown Hospital, and was placed under the care of Surgeon B. A. Vanderkieft, U. S. V. He breathed with stertor, and had a slow pulse, dilated pupils, and the other signs of compression of the brain. The scalp was shaved, and an incision was made, through which a number of fragments of detached bone were removed. The patient lingered, in a state of stupor, until November 8th, 1862. The particulars of the case are not recorded in the register or in the reports from Smoketown Hospital; but the only death in the hospital from fracture of the cranium, at the date referred to, is that of Sergeant Arthur F. Hascall, Co. C, 61st New York Volunteers. The fracture extends downwards from the sagittal suture three inches, and it is an inch wide at its lowest part. A few fragments are adherent to the inner table, and the edges of the orifice are carious. The specimen is represented in the adjoining wood-cut, (Fig. 21.) The contour of the aperture in tlie bone represents, with exactness, the outline of the edge of the spade. The specimen was forwarded to the Army Medical Museum by Surgeon Vanderkieft, by Hospital Steward A. Schafhirt, U. S. A. The latter states that a detailed history accompanied the specimen. A careful search has failed to discover this paper, and the registers of the Museum contain no indication of its reception. Trephining. — The following eighteen abstracts of cases of fracture of the skull from various causes other than gunshot injury, refer to instances in which the trephine was formerly applied: Case. — Private Joseph Bums, Co. C, 4th Kentucky Cavalry, aged 23 years, was struck on the head at 8 o’clock r. m., February 22d, 1834, by a slung shot, which produced a fracture of the skull, extending from the vertex to the left orbit, through the parietal, frontal, and the great wing of the sphenoid. The patient was taken to Clay Hospital, at Louisville, Kentucky, on the evening of the accident, with symptoms of grave compression of the brain. During the night he had frequent convulsions. Early the follorving morning, Acting Assistant Surgeon John E. Crowe applied the trephine, and elevated the depressed bone. The patient had previously been comatose or convulsed every five or ten minutes; but in ten minutes after the operation he became conscious, and spoke rationally, stating the circumstances attending his injury and his military history. In a few hours, however, the convulsive paroxysms returned, and continued during the night. The patient died on the succeeding day, February 24th, 1834. Surgeon Alexander T. Watson, U. S. V., records the case. Case. — Private Patrick H. Green, Co. H, 125lh New York Volunteers, while on furlough, received a blow on the left side of the head from a slung shot, on the night of May 23d, 1863. He was treated by a private physician until June 3d, when he was admitted into the Ladies’ Home Hospital, New York City. Twenty-four hours after his admission he had a spasm of the right side of the body, and, upon examination, there was found to be a depressed fracture of the skull. The scalp was laid open by an incision, and trephining was performed, and the depressed portions of bone were removed. The scalp.-wound was united by sutures, and a compress of cloths wet with tepid water wmre applied. Rest and quiet were enjoined. The convulsions ceased after the operation, and the wound discharged freely. The patient progressed favorably, and was discharged from service on September 21st, 1863, for hemiplegia. Acting Assistant Surgeon John W. Robie reports the case. Case. — Private Charles H , Co. G, 61st Ohio Volunteers, aged 37 years, was found lying in the street, at Alex- andria, Vii'ginia, on September 27th, 1863, in a comatose condition, with a wound on the right side of his head. He was conveyed to the New Hallowell branch of the 3d Division General Hospital, by the provost guard. On admission his breathing was stertorous, laborious, slow; his pulse was at 48, full and regular. There was a punctured wound over the lower portion of the right parietal, and an examination by the probe showed that the bone rvas fractured and depressed. A crucial incision was made through the scalp, and the cranium being freely exposed, it was found that the fracture was much more extensive than had been supposed. A disk of bone was removed by the trephine, and several detached pieces were removed by the elevator, so that, altogether, a portion foui’ inches in length by two inches in width of the skull-cap was taken away. The flaps of the integument were then brought together and were united by sutures. Cold water dressings were applied. The immediate effects of the operation were very remarkable. Iii less than three minutes after the removal of the de- pressed fragments, the patient opened his eyes, and appeared to awake to consciousness, and in less than a minute more he spoke, articulating dis- tinctly. For the first week after the operation his diet was restricted to barley water. On October 4th, seven days after the operation, ho was reported to have had no bad symptom and he complained of nothing but hunger. The sutares had been removed, and the greater portion of the incision had united by first intention. lie was now allowed the “extra diet” of the hospital, consisting of oyster broth, i-ice [ludding, and the like. On October 2()th, the patient was uj) and about the ward. No untoward symptoms had intervened meanwhile, and the treatment had been nnclianged. At this date the ptitient was ))Ut < u “half diet,” and the nearly cicatriiied wound was dressed with simple cerate. lie continued to do well until November 2{.th, when he was visited by his brother, who brought him some bad news from home which disturbed him very much, and he immediately went to bed and became stupid and sullen, taking no notice of auvtiung. Is it not possible that his brother brought 8 Fig. 22. — Section of cranium with great less of sub- stance from the removal of dcprcHsecl frag^ments. — Spec* 2673. Sect. 1, A. JI. M. 58 WOUNDS AND INJUPJES OF THE HEAD liini some stimulant as well? On October 27tli, tlie i)atient bad become comatose, with every sign of compression of the brain, and on October 28th, 1863, he died. At the autoj)sy, twenty hours after death, there was found to he an abscess in the right hemisphere and the neighboring brain substance was softened. The thoracic and abdominal viscera were healthy. The edges of the apcrtur(i were found to be rounded off and in process of repair. The notes from which the abstract is compiled were made by Acting Assistant Surgeon S. B. Vf ard, and the specimen was forwarded to the Army Medical Museum by Surgeon E. Bentley, U. S. V. It is represented in the wood-cut (Fig 22) on the preceding page. Case. — Private John T. Jcnl-ins, .5th Alabama Eegiment, was received into a regimental hospital at Union Mills, Fluvanna county, Virginia, in October, 1861, suffering from compression of the brain, produced by a blow. The skull was extensively fractured. Trejihining was unsuccessfully performed. The patient died on October 26th, 1861. The case is noted on a monthly report of sick and wounded signed by Surgeon A. Venable, C. S. A., and no further particulars can be obtained. Case. — P rivate William 11. Lowery, Co. C, 6th Tennessee Cavalry, aged 22 years, was wounded in an affray at Slem- phis, Tennessee, October 3d, 186-1, receiving a punctured fracture of the right parietal bone, near its superior posterior angle, produced by a blow of a musket, the hammer passing through both tables of the cranium. He remained in the regimental hos- pital until October 13th, when he entered Gayoso Hospital. He was somewhat drowsy and stupid, but no other symptoms of compression existed. On the following day he Avas put under the influence of chloroform, and Acting Assistant Surgeon Julius Broy trephined the skull and removed a circular portion of the outer table and three depressed fragments of the inner table. The tip of the little finger could be introduced through the opening made in the skull, and it appeared that there Avas no injury to the dura mater. Cold Avater dressings Avere applied to the Avound. The patient Avas restless for several days, and slightly delirious at night. Symptoms of cerebral disturbance Avere thought to be favorably modified by the use of the extract of Can- nabis Indica. On October 18th, an intcrcurrent attack of pneumonia supervened. On November 3d, there Avere signs of cerebral hernia. Protrusion of the cerebral substance progressed so rapidly, that on November 6th, it Avas deemed expedient to compress the fungous mass by a bladder of ice. On November 7th paralysis of the left arm Avas observed. On the 16th, the cerebral hernia Avas still further compressed by a metallic disk. Coma supervened, and the patient died, November 17th, 186-1. Surgeon T. N. Burke, U. S. V., furnished the notes of the case. Case. — Private E. Miller, Co. G, 6th Virginia Cavalry, aged 17 years, Avas Avounded, in a railroad collision on the Ohio and Mississippi Railroad, near Carlisle, Illinois, June 21st, 1865. He Avas taken to IllinoistoAvn, under the care of his regimental surgeon. Dr. A. II. Thayer, and Avas thence sent to the Marine Hospital, St. Louis, Missouri, Avhere a depressed fractui’e of the cranium Avas diagnosticated. Assistant Surgeon S. M. Horton, U. S. Army, decided that the symptoms of compi’ession of the brain demanded an operation, and applied the trephine, and remoA’ed several fragments of bone; but the symptoms Avere not relieved, and the case terminated fatally in the night of June 23d, 1865. Surgeon T. F. Azpell, U. S. V., reports the case. Case. — P rivate Sumner H. Needham, Co. I, 6th Massachusetts Militia, on April 19th, 1861, during the attack upon his regiment, by riotous insurgents in Baltimore, Maryland, was struck on the forehead by a brick, Avhich fractured the frontal bone. He AA'as conveyed to the Baltimore Utiiversity, Avhere his wound Avas examined by Dr. William A. Hammond, Avho found symptoms of compression of the brain demanding the application of the trephine. The operation Avas immediately performed by Dr. Hammond, but the symjitoms Avere not relieved, and the patient died in a feAV hours, April 19th, 1861. Mr. Needliam, a I'esident of LaAvrence, Massachusetts, was one of the earliest victims of the rebellion.* Case. — ^A negro, Avhose name Avas unknoAvn, Avas brought into the E Street Infirmary, Washington, D. C., Avith Avell marked symptoms of compression of the brain, in the latter part of February, 1864. He Avas examined by Assistant Surgeon J. W. S. Gouley, U. S. A., Avho found a Avound over the right parietal pro- tuberance, caused apparently by a bloAV from the head of an axe. The scalp Avas shaved, and it Avas found that there Avas a depressed fracture of both tables of the skull, Avith detachment of a large fragment. It Avas not practicable to insert the elevator to raise the depressed fragment; to allow this to be done, a disk of bone Avas removed by the trephine. A triangular fragment, measuring an inch bj- one and a (piarter inches, Avas then removed and the flaps of the scalp Avere approximated. The symptoms of compression Avere relieved, and the patient Avas doing Avell three days subsequently, Avhen the specimen, rep- resented in the adjacent Avood-cut, (Fig. 23), Avas forivarded to the Army Medical Museum. The facts above noted are taken from a minute, made upon the reception of the specimen, hy Surgeon John H. Brinton, U. S. V. It has been impracticable to learn the ultimate result of the case; but a letter from the late Assistant Surgeon T. G. Mackenzie, U. S. A., dated March 25th, 1864, states that the man Avas doing Avell at that date, though his left arm Avas paralyzed. Dr. Mackenzie refers to an escape of brain substance at the time of the injury; and Dr. Gouley, in forwarding this letter, states that at least half an ounce of brain matter Avas lost, and comments on the singular good fortune of the patient in recovering Avithout the supervention of cerebral hernia, and Avithout loss or ajiparent impairment of the mental faculties. Case. — A. B. Parish, Quartermaster’s Department, received a lacerated Avound of the frontal region, Avith fracture and depression of the frontal bone, by a kick from a horse, near Natchez, Mississippi, September 13th, 1864. He Avas admitted to the hospital, at Natchez, on the same day, in a semi-comatose condition. Soon after his admission. Acting Assistant Surgeon James S. King administered chloroform, and trephined the skull, and raised the depressed portion of bone Avith the elcA'atoi'. The patient soon reacted. Tonics, stimulants, and loAV diet, Avere ordered. The patient gradually improved, and Avas discharged from the hospital, entirely cured, on October 13, 1865. * llecord of the Massachusetts Volunteers, 1801-1805. I’ublishcd hy the Adjutant C5eneral, under a Kesolve of the General Court. Quarto. Boston, 1868, vp- Vol- I, p. ^4. TREPHINING. 59 Case. — Private P , 14th Tennessee Confederate Infantry, aged 25 years, small in stature, but muscular, received, in a quarrel, a wound on the anterior portion of the parietal bone, from a stone held in the clenched fist of his adversary. He was stunned by the blow. Fearing punishment, he did not report at sick call for several days, when he was compelled to do so because of the supervention of erysipelas. He was soon relieved of this complication ; but in a few weeks, became subject to epileptic paroxysms, which recurred every four or five days. He was discharged for disability, and went to his home, at Springfield, Tennessee. Convulsions recurred with such fi-equency and violence that he went to Nashville in May, 1862, to be treated by Dr. W. T. Briggs, of the medical school in that city. His general health was poor, the countenance pale, the bowels torpid, the pulse quick and irritable. A depression of the skull corresponded with the cicatrix of the original wound. There was no pain about the cicatrix ; but a sense of pressure on the whole side of the head. After ten days of preparatory treat- ment, Dr. Briggs, assisted by Drs. Bowling and Buchanan, removed a disk of bone with the crown of a very large trephine. The inner surface of the disk presented a sharp angle at the union of the edges of the depressed inner table. Special instructions were given that the patient should rest quietly in bed, but he disregarded these instructions, yet the wound healed in ten days, and there was no recurrence of the convulsions. He reentered the Confederate service, as a so-called “ Bartizan Ranger,” and was captured and sentenced to be hung, but escaped before the sentence was executed; and, under these exciting circumstances had no return of epilepsy. The abstract of the case is compiled from a report by the operator.* Case. — Private James Rogers, Battery L, 4th Ohio Artillery, was struck on the head by a stone on Jlay 3d, 18G5, receiving a depressed fracture of the skull. He was admitted to the hospital at New Creek, Virginia, on May 7th, in a comatose state. He remained in this condition until May 9th, when he was placed under the influence of ether, and Assistant Surgeon S. IM. Finley, 22d Pennsylvania Cavalry, applied the trephine and elevated the depressed bone. The patient reacted well, and simple dressings were applied. Erysipelas supervened, but was successfully combated by chloride of iron. The patient improved rapidly, the wound was cicatrized, and he returned to duty, well, on June 29th, 1865. Case. — Private John R , Co. H, 2d Michigan Volunteers, aged 41 years, was wounded on July 17th, 1865, in a street affray, receiving four wounds of the head from stones thrown at him. He was admitted to Armory Square Hospital, Wash- ington, D. C., on the following d.ay. He was perfectly conscious, yet had marked contraction of the pupils, with accelerated pulse, and a tremulous voice. There was considerable ecchymosis about the orbits. The first wound examined was over the frontal eminence, and penetrated no further than the aponeurosis of the occipito-front.alis muscle. The second was in the centre of the coronal suture, and slightly denuded the pericranium. The third was in the right temporal region, and likewise was a scalp wound. The fourth was on the right parietal eminence; and, upon a close examination, it was discovered that a minute depression of the bone, half an inch in diameter, existed, evidently produced by a blow from the sharp edge of the stone. The patient was a stout, muscular man, in good health; he suffered no nausea, and little pain. He was immediately placed under the influence of ether, and Surgeon D. W. Bliss, U. S. V., after shaving the scalp, made a crucial incision three inches in length, having the wound at the intersection of the incisions, and then, reflecting the flaps, applied the crown of a trephine and removed a disk of bone, which was found to include, with remarkable exactness, a depressed fragment of the vitreous plate. Between the diploe and depressed lamina there was a coagulum. The dura mater was unmjured. The wound was partly closed by four sutures, an opening being left over the perforation, into which a pledget of charpie was inserted. The patient recovered favorably from the anes- thetic, and was jmt to bed and ordered to observe perfect quiet and strict diet. The case proceeded without an unfavoi-able symptom. On July 23d, the sutures were removed. On July 24th, the compress of charpie was taken away, and a healthy granulating surface appeared beneath. These facts in regard to the case were reported by Assistant Surgeon Charles A. Leale, U. S. V. The pathologi- cal specimen was presented to the Army Medical iluseum by the operator, and is represented in Photograph No. 87 of the Surgical Section of the Army Medical Museum, and in the accompanying wood-cut, (Fig. 24.) The disk is seven-eighths of an inch in diameter, and is slightly reduced in the illustration. On August 24th, 1835, the patient was transferred to Harper Hospital at Detroit, Michigan. The case continued to progress favorably, and the man recovered without a bad symptom. He was discharged from service on September 8th, 1865. Fig. t34. — External and infernal views of a button of bone removed for a depressed fracture by a blow fi'oni a stone. — Spec. 1452, Sect. I, A. M. II. Case. — Private James C. Shedd, Co. D, 11th New York Cavalry, aged 19 years, was thrown from his horse to the pavement, while riding through the streets of New Orleans, Louisiana, April 10th, 1834. There was a compound comminuted fracture of the cranium, confined principally to the external table, which was depressed about au inch and a half in length and half au inch in depth. He was conveyed to the University Hospital, being in a stupid condition, in consequence of the concussion and the influence of liquor; but, at times, he was restless, and could be aroused for brief periods only by determined eflbrts. Shortly after admission he was placed under the influence of chloroform. Surgeon Samuel Kneeland, U. S. V., then enl.arged the wound of the scalp, which was found much torn and bruised, and trephined the skull at the anterior jiortion of the right parietal region, removing several pieces of bone and elevating others. Cold water was applied to the wound, rest and (luiet enjoined, and light diet ordered. The case progressed favorably, with very little cerebral disturbance, and on the Itlth of June, 1854, the patient was discharged from the service, .as a long time would be necessary for the exfoliation of the bone, extensively denuded of periosteum. His general health and strength were excellent. Case. — Jesse Smith, Freedman, aged 18 years, employed as a cattle driver, rolled olf, in his sleep, from the hay in a stable loft, and fell, some twelve feet to the floor, striking his head. He was found in the morning, cold and insensible, lying on the stable floor, near the horses. Under the use of frictions, hot drinks, and other restoratives ho revived, and was carried to the Freedmen's Hospital, at Ale.xandria, Virginia. Acting As.5istant Surgeon Robert N. Atwood, found a wound of the scalj) of a crucial form over the right parietal eminence, and a depressed fracture of the bone; but, as the general condition of the 'The Nashville Jounial of Jledicine and Surgery, New Scries, 186(1, Vol. I, p. 35. 60 WOUNDS AND IJUPJES OF THE HEAD, Fig. 25. — Disk and depressed fi’ai^inent of bone fn)m right parietal. — Sjjec. 4817, Sect. I, A. M. M. patient was comfortable, sensibility being restored, and the mental faculties being apparently normal, Dr. Atwood decided to await further developments. No decidedly bad cerebral symptoms appeared for twelve days after the injury, when the patient complained of increased lieadaohe, and a few hours subserpiently had a severe convulsion. On the following day, the patient was much the same as usual, except that his headache was increased. Dr. Atwood, in considtation with Acting Assistant Surgeon A. yV. K. Andrews, decided to operate, and (;ther having been administered, enlarged the original wound and applied the treitbine, and i-emoved a button of bone to which the greater portion of the depres.sed fragments were unit(.‘d by the inner table. On removing the bone, pus gushed out copiously. At the upper posterior part of the perforation the inner table was detached three-fourths of an inch more -than the outer. This fragment was, with some difficulty, removed by strong forceps. An hour afterwards, the patient having recovered from the ether, was highly excited, restless, anil complained of intolerable pain. He was ordered a grain of sulphate of morphia, and in two hours slept comfortably. For ten days subsequently, the morphia was continued, being given to the extent of two or three grains daily. His diet, at this time, was bread and milk, in small quantities, acidulated with vinegar, wliich he craved earnestly. Pie also had vinegar and water to drink. In three days after the operation the brain commenced to protrude through the opening in the skull, and by the tenth day had attained the size and shape of half of a hen’s egg. Dr. Atwood decided to try, by gentle compression, to reduce the protru- sion, and applied a compress and retentive bandage with this view; but immediately violent convulsions occurred ; and, although the compress was instantly removed, violent convulsive paroxysms recurred during the night, not less than fifteen or twenty times. The next day the patient was hovering between life and deatb, but he gradually rallied, and str.ange to say, after the subsidence of the convulsions he had no more pain in his head. His bowels bad been regular throughout his illness, and he had taken no medicine except the morphia, which was discontinued as soon as the pain in the head ceased. Convalescence proceeded rapidly; the protrusion subsided; a firm and dense cicatrix covered the aperture in the .skull; and the patient recovered without any impairment of his mental faculties or motor powers. Several months after his recovery he was brought to the Army Medical Museum to be photographed. The picture is numbered 185 in the Surgical Series. The boy was then in perfectly good health, and his faculties were unimpaired. The specimen of the disk and depressed fragment of the parietal was presented to the Museum by Dr. Atwood, and is figured in the accompanying wood cut, (IHg. 25.) Case. — Private W. H. South, Co. H, lG8th Pennsylvania Volunteers, while quartered in a house, at Washington, North Carolina, fell down stairs. May 13th, 1833, and struck upon the left side of his head. The medical officer of the garrison, As.sistant Surgeon P. E. Hubon, 27th Massachusetts Volunteers, was summoned, and found that there was a stellated fracture of the cranium, one fissure running over the occipital bone, another fissure through the petrous portion of tbe left temporal, and a third e.xtending to the left orbit. At the point of impact the left parietal was much depressed. The patient was unconscious, and stertorous breathing, dilated pupils, and other evidences of comjiression of the brain existed. Dr. Hubon api)lied the trephine and elevated the depressed bone. The patient did not regain consciousness, and died thirty-nine hours after the accident. May 15th, 1863. The case appears on the monthly report of the Post Hospital, Washington, North Carolina, for Jlay, 1863. Case. — Private Charles E. Towns, Co. I, 9.th New Hampshire Volunteers, was thrown from his horse, and falling upon his head, received a fracture of the cranium. He was treated in the regimental hospital until February 1st, 1865, when ho was admitted to the hospital of the Second Division of the Ninth Army Corps. The accident is not recorded on the regimental reports, and it is impracticable to ascertain its date. Such facts as are known are derived from the report of the Corps Hospital. On tile patient's admission it was decided that compression of the brain with depressed bone existed; and the operation of trephining was performed by Surgeon L. W. Bliss, 51st New York Volunteers. The date and other particulars are wanting. The jiatient died, February 20tb, 1865. The case was reported by Surgeon F. N. Gibson, 9th New Hampshire Volunteers. Case.— Private Charles Williams, Co. B, 161st New York Volunteers, was admitted into St. Louis Hospital, New Oi'leans, Louisiana, January 12th, 1835, with an extensive fracture of the cranium and compression of the brain, caused by a blow received in a steamboat collision, January 9th, 1835, between the U. S. Transport J. H. Dickey and the Transport John Eain, on the Mississippi River, fifteen miles below Vicksburg. The trephine was applied and a portion of depressed bone was elevated, and another portion was removed. The p.atient died on January 18th, 1835. Surgeon A. McMahon, U. S. V., records the case on his monthly report without particulars of the operation or after treatment. Case. — Private Charles V , Signal Corps, received, on February 24th, 1832, at Georgetown, D. C., a kick from a horse; the sharp cork of the shoe penetrating the cranium at the anterior inferior angle of the parietal bone, driving frag- ments of the internal table inward, penetrating tbe dura mater and rupturing the middle meningeal artery. He was seen by Assistant Surgeon John S. Billings, six hours after the reception of the injury. He was comatose, and presented the usual signs of compression of the brain from depressed fractui-c. Dr. Billings applied the trephine and removed the depressed fragments, and also about two ounces of coagulated blood. The jiatient immediately came to his senses, and did ■well for four days, when symptoms of cerebro-meningitis set in. The patient was then transferi-ed to the ITnion Hotel Hospital. Active treatment was unavail- ing, and dc'atb followed in two days, or on March 2d, 1862. The autopsy showed effusion of lyinj)!! over the whole of the right hemisphere of the cerebrum. A portion of the cranium, showing the extent of bone removed, was contributed, with a memorandum of thci case, to the Army Medical Museum by Dr. Billings. , , „ , ilepre.sscd iracturc from the kick of a horse. — i>pcc. It is represented in tbe adjacent wood cut, (I IG. 26.) 345J, Sect. I, A. M. M. ANALYTICAL EEVIEW. 61 Five hundred and eight cases of injuries of the head, resulting from railroad accidents, falls, blows, or analogous causes, have been enumerated in the foregoing pages of this Section. They comprise nearly all of the cases of this nature reported by name during the war ; all, in fact, in which the nature and seat of the injury could be satisfactorily verified. A large proportion pertain to the two latter years of the war, when the system of reporting had been perfected. A few cases, about eighteen altogether, have been gleaned from the Confederate records. Of the whole number of five hundred and eight cases, three hundred and thirty-one were contusions or lacerations of the integuments, without serious primary or secondary injury to the skull or its contents ; seventy-two were examples of injury of the head affecting the brain, but without fracture of the skull ; and one hundred and five were instances of fracture of the skull. In the first class, all of the patients recovered, though there were many instances of troublesome complications from heemorrhage, abscesses under the scalp, erysipelas, and sloughing. In the second class, the percentage of complete recovery was small, as fourteen of the cases terminated fatally, and fifty-three patients were discharged for disability. In the third class, the mortality was large, fifty-seven of the one hundred and five patients having died. Of the five hundred and eight cases, seventy resulted from railroad accidents, seventy- eight from falls, two hundred and six from blows, and one hundred and fifty-four from unspecified causes other than gunshot, the sabre, or the bayonet. Analyzing the seventy cases of injuries by railway accidents, it is found that forty- nine were contusions and lacerations of the integuments, attended, in some instances, with the temporary effects of concussion, or by erysipelas, sloughing, or burrowing of pus. Thirty-five of these forty-nine men were returned to duty, and fourteen were discharged for disability. Eleven were cases of severe concussion, or contusion, or laceration of the brain, and of these patients, two were returned to duty, one was furloughed and not heard from afterwards, one was discharged as permanently blind, one died from pulmonary com- plications, and six died from the effects of the accident. Ten were cases of fracture of the skull, and, of these patients, one was returned to duty, one was transferred to the Veteran Reserve Corps, one was discharged, and seven, including one who had been unsuccessfully trephined, died. In short, of the seventy patients reported with injuries of the head from railroad accidents, thirty-nine went to duty, seventeen were discharged,'*’ and fourteen died. Of the seventy-eight cases of injuries of the head from falls, forty-three were exam- ples of contusions or of contused or lacerated wounds, followed ultimately by recovery. Seventeen were attended by grave concussion of the brain, or other serious complications, and of these seventeen patients, three were returned to duty, nine were discharged, one was transferred to the Veteran Reserve Corps, one deserted, and three died. Eighteen were cases of fracture of the skull, and thirteen of them were fatal. Five of the eighteen patients were subjected to trephining, or the removal of fragments, or the elevation of depressed bone, and three of the five recovered. In brief, forty-nine of the seventy-eight patients were returned to duty, twelve were discharged, sixteen died, and one was doing well at the last report, fifteen days after undergoing an operation for the elevation of depressed bone. * In the summaries, the m(!n transferred to modifiesd duty in the Veteran Reserve Corps, are included with fliose returned to duty, and the furloughed men, not heard from, and the deserters, witli those discharged. 62 WOUNDS AND INJUEIES OF THE HEAD, Of the two hundred and six cases of injuries of the head from blows, the scalp alone was seriously involved in one hundred and eighteen ; six of these patients deserted, and the remainder were returned to duty. Thirty-six cases were attended by cerebral complications ; of these men, three went to duty, three to modified duty in the Veteran Reserve Corps, twenty-seven were discharged, and one died, while in two cases, the ultimate result has not been ascertained. Fifty-two were instances of fractures of the skull, and of this series of patients, seven recovered and were returned to duty, one was transferred to the Veteran Reserve Corps, fourteen were discharged for disability, twenty-eight died,'^ and in two cases the result is undetermined. Operative interference was employed in twenty of the fifty-two fractures. One of the patients went to duty, six were discharged, and eleven died, and in two casesf the ultimate issue has not been ascertained. The results of the two hundred and six cases may be thus recapitulated : one hundred and twenty-six went to duty, forty-seven were discharged, twenty-nine died, while in four cases the results are undetermined. Of the one hundred and fifty-four cases of injuries of the head from unspecified causes, one hundred and twenty-one refer to uncomplicated contusions or lacerations of the scalp. One hundred and thirteen of these patients returned to duty, and eight deserted. In eight cases, the brain or its membranes were involved, and four of these patients were discharged on account of deafness, paralysis, or impairment of the mental faculties, one was transferred to the Veteran Reserve Corps, and three died. Twenty-five cases are reported as instances of fracture of the skull ; but in several of the cases the diagnosis is not beyond suspicion. Six of these patients are reported as returned to duty, two were furloughed, eight were dis- charged for disability, and nine died. In brief, of the five hundred and eight patients with wounds and injuries of the head, three hundred and thirty-four were returned to duty, ninety-eight were discharged, seventy- one died, and, in five cases, the results are undetermined. The Contusions of the Scalp, from miscellaneous causes, may be conveniently sub- divided into those in which there was laceration of small vessels in the areolar tissue and limited effusion of blood ; those attended by extensive ecchymosis ; and those in which the tissues were pulpified and disorganized. J The uncomplicated contusions of the scalp, without external breach of surface, that were treated in hospital, generally required but little surgical interference. They were commonly dressed with a spirit or lead lotion, at first, or by an ice bladder, or the frigorific mixture of hydrochlorate of ammonia, saltpetre, and salt, recommended by Hennen^ and Schmucker,^ conjoined with elevation of the head, and an antiphlogistic regimen. No instance of the application of leeches is mentioned. When a large amount of effused blood remained long unabsorbed, bandaging, with moderate compression, stimulating frictions, and general treat- ment were sometimes employed. In a few cases, the bad practice of incising the tumor and squeezing out the coagulum, is reported to have been adopted, with the result of inducing inflammatory action and unhealthy suppuration. * The case of Wiggins, on page 50, should have been recorded as fatal. He died on April 14th, 1865. t Already referred to among the fifty- two fractures. iDupuytreu, it is well known, classified contusions in four degrees, {Logons Oralcs, T. IV, p. 267;) but even the French surgeons admit that either the third or fourth division is “unpeu arbitraire.” See Follin, Traite de Fathologie Lxterne, T. I, p. 386, Paris, 1869. ‘ Hennen. Principles of Militwnj Surgery, 3d ed., London, 1829, p. 283. SCHMUCKEE, J. L. Chirurgiseke Wahrnehmungen. Berlin und Stettin, 1774, Erster Theil, S. 89. ANALYTICAL REVIEW. 63 In quite a large number of the contusions of the scalp, there was great extravasation of blood under the occipito-frontalis tendon ; and, in several of these cases, suppuration ensued. They were judiciously treated by free incisions at the most depending parts, the courses of the larger arterial branches being avoided, and by the subsequent application of warm water dressings. Though complicated, in a few instances, by erysipelas and slough- ing, recovery eventually resulted in all of these cases. There were also examples of bruises of the scalp, with effusion of blood in the meshes of the condensed cellular tissue connecting the common integument with the occipito-frontalis aponeurosis, producing that remarkable condition in which, the effused blood coagulating imperfectly, the portion in the centre remaining fluid, and the scalp being apparently depressed at this point, a depressed fracture is closely simulated. These circumscribed bosses, hard at the circumference and soft and depressible in the centre, were more frequently observed over the lateral regions of the skull. Fortunately, there were no symtoms of affection of the brain in these cases, and the attendants wisely refrained from cutting down upon the bone. Resolvent lotions and the popular plan of compressing the bump by one or two coins or a bit of folded sheet lead, appeared to expedite absorption. In two cases, the plan proposed by Champion,^ of sud- denly compressing the tumor by a blow severe enough to rupture the sanguineous cyst and to cause the blood to be infiltrated into the neighboring cellular tissue, was employed with good results. In these cases, a peculiar crepitation, due doubtless to broken fragments of fibrinous coagula, was observed. There were a few instances in which the surface of the scalp was unbroken while the tissues composing it were crushed so as to be irretrievably disorganized. These cases were treated by warm emollient applications, until the gangrene that ensued had ceased, and the sloughs had separated, and granulation began ; when the usual means of promoting cicatriza- tion were employed. The Contused and Lacerated Wounds of the Scalp will be so fully considered in the section on gunshot wounds of the head, that few comments will be required in this place. In examining the detailed histories of the several hundred cases barely enumerated in the foregoing part of this- Section, examples are found of almost every variety of injuries of this nature, from slight solutions of continuity, resembling incised wounds, to nearly complete denudations of the calvarium. As a general rule, the treatment of these lesions appears to have been simple and judicious. That axiom of practical surgery which forbids, in the treatment of scalp wounds, the sacrifice of the smallest portion of damaged integument, was almost universally observed ; and the means adopted of replacing and connecting detached flaps of integument were usually well selected. In several cases, very large portions of the scalp were described as nearly torn away, hanging by slender pieces of skin. Such injuries were caused, in two instances, by blows from muskets ; but more frequently by falls, or by the passage of the wheels of heavy wagons, caissons, or gun-carriages, over the side of the head. In these cases, after suppressing haemorrhage, on the rare occasions in which it was troublesome, after cleansing the pendulous flaps from the dirt, gravel, or other foreign bodies adhering to them, and after divesting them and the adjacent scalp of hair, it was customary to replace the flaps, and maintain them in position, either by agglutinative plasters, or by sutures. In most cases, the dressing was completed by the application of compresses dipped ' Archives Generales de Medecine, Premiere S6rie, 1827, T. XV, p. 139. 64 WOUNDS AND INJUPwIES OF THE HEAD in cold water, and maintained by a bandage. In some instances, layers of raw cotton, cbarpie, or iDicked oakum, were arranged as graduated compresses upon the flaps. A few surgeons preferred to apply poultices or warm-water dressings, if the scalp was much mangled. In all of the cases of detachment of large flaps, it would app'ear that the peri- cranium was fortunately left entire ; and, though many of these cases were complicated by erysipelas, sloughing, or by the bagging of pus, the wounds granulated after awhile, and -all eventually cicatrized. No instance was reported of any special inconvenience arising from the employment of stitches. In one case, a very long wound was sewed up by the continued or Glover’s suture, without bad consequences. Usually, when adhesive plasters were con- sidered insufficient to approximate the edges of the wounds, the interrupted suture with metallic threads was employed. Assistant Surgeon J. S. Billings, U. S. A., reports a lacerated wound of the scalp neatly approximated by tying together the hairs bordering the retracted edges of the wound. This expedient answered a good purpose, cicatrization following as promptly as usual under more methodical dressings. In scalp wounds with little separation of the edges, adhesive plasters were the ordinary dressing. The importance of adjusting the parts with the nicest accuracy, and of leaving sufficient intervals between the strips, with the lower angles of the wound open, was gen- erally appreciated. The propriety of removing the dressings as infrequently as practicable was commonly recognized. In the hospitals about Philadelphia, the gauze and collodion dressing recommended by Dr. P. B. Goddard found favor ; but the isinglass and resin plasters, supplied by the field medicine-chests and knapsacks, were the agglutinatives com- monly employed. In a few cases, it is stated that the old-fashioned Friar’s Balsam'-’' was advantageously employed. The complications arising in this class of wounds of the scalp were haemorrhage, erysipelas, abscess, and sloughing. Several instances of troublesome bleeding from the posterior auricular, occipital, or temporal arteries, or their branches, are reported ; but, in every case, the hemorrhage was controlled by compression, either by the clamp tourniquet, or the common tourniquet, or by a circular bandage and compress, or by a compress con- sisting of a metallic disk. In one case, a profuse secondary bleeding from the temporal was arrested by dividing the vessel transversely, and suffering it to retract. Persulphate of iron, in powder or solution, was employed as a styptic in several cases ; but not with advantage. In a case in which it appeared that ligation must be resorted to, acupressure was suggested as peculiarly appropriate ; and preparations to use this resource were made, when the bleeding, being controlled by pressure, ceased, and did not recur. Erysipelas was not a very frequent complication, being reported in but thirteen of the four hundred and three cases unattended by fracture. Nearly all of the cases in which it supervened were attended by symptoms of affection of the membranes of the brain, or of the brain itself ; yet, with one exception, (Kirkland, p. 53), they terminated favorably, under the supporting and stimu- lating treatment uniformly adopted. There were numerous instances of abscesses under the scalp, due apparently, in most cases, to negligence in keeping the detached scalp in apposition with the subjacent parts by gentle bandaging, or to the retention of clots of blood under the flaps. Incisions, followed by fomentations and poultices, and the washing out of the cavity of the abscess by warm detergent solutions, appears to have been the ordinary treatment. In many of the contused and lacerated wounds, there was slight loss of tissue from gangrene, * Compound Tincture of Benzoin, or Baume du Commandeur, or Teinturc halsamique of the French Codex. ANALYTICAL REVIEW. 65 and in two cases, very large portions of the scalp sloughed away, yet the exposed surface was soon covered with florid granulations, and rapidly cicatrized. ' Detergent or stimulating lotions were employed in these cases, and solutions of the salts of zinc or the permanganate of potassa were the applications commonly selected. Concussion of the Brain . — It will he remembered that the five hundred and eight cases of injuries of the head from miscellaneous causes were classified, on page 61, in three divisions ; the first comprising three hundred and thirty-one cases of injuries of the integ- uments chiefly ; the second, seventy-two cases of severer injuries, with cerebral complica- tions ; and the third, one hundred and five cases of fractures of the skull. In the second class were placed only those cases which terminated fatally, or in discharge for disability, or in return to modified duty after protracted disability. But concussion of the brain, temporary in its effects, was observed in a large proportion of the three hundred and thirty- one slighter cases enumerated in the first class ; and, in fifteen of them, this complication was .attended by profound insensibility and collapse and appeared, at first, to be very serious, though speedily followed by reaction and recovery. Severe commotion or concussion of the brain was observed in fifty-nine of the seventy-two cases of the second class, or, altogether, in seventy-four of the four hundred and three cases of miscellaneous injuries of the head without fracture. The treatment of this condition usually consisted in wrapping the patient in hot blankets, and applying bottles of hot water to the extremities, in employing frictions, and sinapisms, and stimulating enemata; and, after reaction was established, in prescribing purgatives, low diet, and rest in bed. The precautions suggested by authors respecting the use of volatile salts, cordials, and venesection during the stage of collapse, appear to have been observed uniformly. The management of the stage of reaction appears, also, as a general rule, to have been prudent and judicious ; but many exceptions, due sometimes to the exigencies of the situation, and sometimes to the negligence or officiousness of the attendants, are noticed, in which quiet and abstinence were not enjoined, or stimulants and full diet were ordered in obedience to false therapeutic dogmas in preference to the lessons of experience. To these causes, probably, must be attributed the considerable number of instances in which concussion was followed by cerebral irritation or encephalitis, complica- tions which will be considered further on. In one case of concussion, (Sherman, p. 41,) when reaction was becoming over-action, venesection was practiced, with apparent advantage. In one case, concussion produced almost instant death, (Turner, p. 44 ;) but neither this nor the thirteen other cases which resulted fatally from the direct effects of concussion, throw any light upon the functional or textural alterations of the brain resulting from this shock, but leave the subject, which has perplexed pathologists for so many centuries, as inscrutable as ever. As has been intimated at the beginning of this Section, the value of the numerical statistics relative to concussion and compression of the brain derivable from “monthly reports of sick and wounded,” would have been greater, if the cases due to miscellaneous causes had always been separated from those resulting from injuries by gunshot projectiles. In the first year, and in a portion of the second year,^ of the war, the reporters failed some- times to make this important discrimination ; but, subsequently, explicit instructions having 9 66 WOUNDS AND INJURIES OF THE HEAD, Leeu promulgated, the gunshot injuries were separately reported. The number of cases of concussion and compression of the brain recorded on the monthly reports is given in the following table ; Table I. Cases of Concussion or Compression of the Brain, generalhj from Causes other than Gun- shot, recorded on the Monthly Reports during the War. Year. Mayand June, IHOl. Year ending June .30, 1862. Year ending June 30, 1863. Year ending June 30,1864. Year ending J une 30, 1865. Aggregate. White 'I’roops. Mean strength in Field and Garrison . , “ “ “ General Hospitals . 41,5r>6 ‘279,590 9,548 630,761 45,630 6‘2‘2,058 55,710 574,0‘2‘2 71,484 515,517 4.5,593 Cases. Deaths. Cases. Deaths. Cases. Deaths. (’ases. Deatlis. Cases. Deaths. Cases. Deaths. Concns.sion of Brain 7 1 144 60 19 17 ‘295 (>2 234 52 193 60 873 61 193 17 Colored Titoors. Mean strength in Fiehl and Garrison .. 46,020 1,222 86,660 .5,572 66,340 3,397 General lloypitiils . Cases Deaths. Cases. Deaths. Cases. Deaths. 18 0 31 13 49 22 This table indicates that in the year ending June 30th, 1862, there was one case of concussion of the brain in a mean strength of 2,008, and that of 144 cases, one in 7.5 was fatal. In the following year, when the concussions from gunshot injury may be supposed to have been generally excluded, there was one case of concussion in a jiiean strength of 2,292, and a mortality of one in 4.7 cases. In the third complete year there was, among the wliite troops, one case of concussion in 2,896, and a mortality of one in 4.5 ; and, in the colored troops, one case of concussion in 2,625 cases, with a mortality of one in 2 cases. In the fourth year, the cases of concussion were, among the white troops, one in 3,344 mean strength, with a mortality of one in 3.2, and, among the colored troops, one in 2,975 mean strength, with a mortality of one in 2.4. The report of Surgeon Thomas 41. Williams, 0. S. A., Medical Director of the Con- federate Army of Northern Virginia, shows that the consolidation of the monthly reports of sick and wounded for nine months, from July, 1861, to March, 1862, inclusive, furnish eighteen instances of concussion of the brain in a mean strength of 49,394. During the *The consolidations for white troops are taken from page 040 of the medical volume of the First Part of the Medical and Surgical History of the Rebellion. The consolidations for the colored troops are furnished me in manuscript by Brevet Lient. Col. J. J. Woodward, Assistant Surgeon U. S. A. After 183.2,- “compression of the brain” was e.'ccluded from the nomencla- ture of the monthly report of sick and wounded. The deaths are understood to be included among the cases : c. g., of 144 patients with concussion of the brain, during the year ending J une 30, 1862, 10 died. • ATJALYTICAL REVIEW. 67 months of September, October, November, and December, 1862, of an aggregate of 48,543 patients in the General Hospitals under the supervision of Surgeon T. H. Williams, 0. S. A., there were sixteen examples of concussion of the brain. All of these thirty-four cases terminated favorably. From the absence, in these reports, of any fatal results from con- cussion, it may be inferred such were probably entered under other headings. Of the Confederate systematic writers on military surgery, the compilers of the official manual' advise, in the early treatment of concussion, the use of external warmth, frictions, and diffu- sible stimuli ; Surgeon J. J. Chisolm^, C. S. A., thinks “ the safest practice consists in doing as little as possible, the indiscriminate use of stimuli on the one hand, or bloodletting on the other, being especially avoided;” while the Surgeon General of North Carolina, E. Warren,^ with strange confusion, “ in order that the pathological difference between con- cussion and compression of the brain may be thoroughly comprehended,” ascribes to con- cussion the signs almost universally believed to attend compression. The “Confederate States Medical and Surgical Journal,” published under the auspices of Surgeon General S. P. Moore, C. S. A., contains no reference to the treatment of concussion of the brain, and the reports and treatises above alluded to furnish the scanty information to be derived from the Confederate records. Fractures of the /Skull. — Of the one hundred and five cases of fracture of the skull recorded in this Section, forty-six were instances of simple and forty-three of comjiound fracture ; while, in sixteen cases, the reports are silent regarding this distinction. Fifty- seven of the one hundred and five cases terminated fatally ; in three cases, the ultimate results cannot be learned ; and forty-five patients are reported as recoveries. The causes of death in the fifty-seven fatal cases were ; compression of the brain from fragments of bone, in sixteen cases; laceration of the brain, in five cases'*; shock and concussion, in two cases ; extravasation of blood, in sixteen cases ; encephalitis, in ten cases ; abscess of the brain, in six cases ; epilej)sy, in one case ; cerebral hernia, in one case. Each of the three undetermined cases was doing well several weeks after the reception of the injury. Of the forty-five patients reported as returned to duty, thirty had simple and fifteen compound fractures, and four of the simple and seven of the compound fractures were depressed. Of these forty-five patients, seventeen recovered wholly, and were returned to duty ; one recovered and was mustered out on the expiration of his term of service ; another recovered I'rom the injury of the head, and was discharged on account of the loss of an arm ; and twenty-six were discharged on account of physical disabilities of various degrees. Epilepsy, in three cases ; hemiplegia or paraplegia, in three cases ; impaired intellectual functions, in two cases ; deafness, in two cases ; imperfecd vision, in one case ; vertigo and cephalalgia on exposure to the sun, in five cases, are the disabilities particularly specified. It is safe to say, that nineteen of the one hundred and five patients with fractured skull recovered com- pletely, that twenty-nine recovered partially, and that fifty-seven died. * A Manual of Military Surgery, prepared for the Use of tlee Confederate States Army, by Order of the Surgeon General. Richmond, 1863, p. 7. '^Chisolm. A Manual of Military Surgery for the Use of Surgeons of the Confederate States Army. Columbia, S. C., 1864, p. 275. ^ Warren. An Epitome of Practical Surgery for Field and Hospital. Richmond, 1863, p. 351. ■* In one of the cases of laceration of the brain (Michaei, B , p. 44) there was cerebral hernia, as well as in the case of Lowery (p. 51), cited two lines further on. In tlie latter, this complication was, appiu-cntly, the proximate cause of death. 68 WOUNDS AND INJURIES OF THE HEAD, All of the cases, twenty-eight in number, of fracture of the skull without injury to the brain or its membranes terminated favorably, with the exce})tion of the case of Private M. Young (p. 39), complicated by a terrible laceration of the testes. Fifty-eight cases in which symptoms of compression of the brain supervened immediately or soon after the recep- tion of the injury, present forty-six deaths, three instances of favorable progress a few weeks after the injury with the ultimate results undetermined, and three examples of complete, and six of partial recovery. In the nineteen remaining cases, cerebral complications appeared at a later date ten of the nineteen were fatal ; eight ended in permanent dis- abilities, through impairment of the mental, sensory, or motor functions ; while only one patient completely recovered. It was observed that fissures or long linear fractures with little depression, as a general rule characterized the fractures of the skull from falls or railroad accidents, while extensive splintering of the internal table was a very frequent consequence of blows from blunt weapons. The portion of the cranium injured is referred to in seventy-eight of the reports, and is indicated in the following tabular statement : Table II. Seat of Injury in One Hundred and Five Fractures of the Skull from Falls, Blows, &c. The far greater fatality of fractures of the side and base of the cranium than of those implicating the anterior and upper portions of the vault, is well illustrated by these figures. There were no instances of fracture of the internal table alone ; but the case of Cahill (p. 64), and that of Sharp (p. 55), afford, perhaps, illustrations of fracture implicating the external table only, over the frontal sinus and at the base of the zygoma. The case of Schneider (p. 41) also, reported among the severe contusions, the patient having been discharged on account of obstinate ozsena from ulceration of the frontal sinus, possibly belongs to the category of fractures of the external table. The frequency of such fractures ‘ At incipcre fehrem in capitis milnerc, quarta die aut septima aut undecima, valde lethale cst. Hippociiates, De Prwdict. Lib. II, Sect. II. Cap. 10. ANALYTICAL REVIEW. 69 has heeii overestimated by Sir Astley Cooper* and other eminent surgical writers. In rare instances, blows upon the mastoid or zygomatic processes, or frontal sinuses, produce such an injury ; but, over the vault of the cranium, a depression of the outer table upon tlie diploe, without lesion of the vitreous lamina, is oftener described in books than demonstrated by pathological preparations.® Of the eleven cases of fracture of the base of the cranium, two were accompanied by that peculiar colorless discharge from the auditory canal which excited so much discussion among surgeons thirty years ago, and which is held to be a positive indication of fissure ol the petrous bone.^ Three cases of fracture .of the base were believed to be instances of fracture by contre-coup. This subject will be fully considered hereafter, and it will be shown that the existence of such fractures, in the sense understood by Grima^ and Saucerotte, may be fairly called in question. In seventy-nine cases of fracture of the skull treated without operative interference, the death-rate was 54.4. Of twenty-six cases operated upon, the ultimate results are ascertained in twenty-three, in which the mortality-rate was 60.8. Removal of Fragments ahd Trephining . — Of the twenty-six depressed fractures treated by the removal of fragments and trephining, five were caused by falls, three by railroad or steamboat accidents, and eighteen by blows. Fourteen of the patients died. Three undetermined cases were progressing favorably fifteen days, three weeks, and four weeks, respectively, from the date of injury. Nine patients recovered, of whom two went to duty, two were discharged though entirely well, and five were discharged for disabilities due to cerebral disorders. In brief, it may be said of the twenty-six cases in which operative interference was employed, that complete recovery took place in four cases, partial recovery in eight cases, and death in fourteen cases. The cases recorded in this Section afford instances of commotion, contusion, laceration, and compression of the brain, of rupture of the meningeal arteries, of cerebral irritation, of perversion or loss of the sensory or intellectual functions, of various paralyses, of puffy tumor and persistent pain in the scalp ; but general observations on these subjects, all of which will appear again in the succeeding Section, may be reserved for the conclusion of this Chapter. * Astley Cooper. Lectures on Surgery, London, 1842, p. 130. Specimen 48.53, Section I, A. M. M., represents a segment of tlie frontal hone of a young man who received a blow fi-om a fireman’s iron “spanner” upon the left superciliary ridge. Such competent observers as Drs. Thomas Miller and Robert King Stone, of Washington, diagnosticated a depression of the outer table of the frontal sinus. Several months subsequently, the patient died from inflammation of the brain, and an extensive depression of the inner table was revealed. Tbe large collection of specimens of fractures of the skull in the Army Medical Museum fails to afford a single example of fractui-e of the outer table singly, if the groovings by shell fragments and incisions hy cutting weapons are excluded. ^ Bereng.arius, in his work on Fractures of the Cranium, published at Bologna, in 1518, first called attention to this phe- nomenon, and Stalp.art Van der Weil, {Obs. rarior. cent, prima, Obs. XV, Leyden, 1728, p. 68,) cited an example, and quoted another from Langelot; but Laugier, in his note to the French Institute, in 1839, pointed out the significance of this discharge in diagnosis. Guima, tSar les Conire-coups dans Ics Ldsions di la Teti. Memoires sur les Sujets proposds pour les Prix de TAcaddmie Royale de Chirurgie. Paris, 1819, T. IV, p. 207; Saucerotte, in the same work, Vol. IV, p. 290. Sabouraut, loc. cit, p. 337, and many others. 70 WOUNDS AND INJURIES OF THE HEAD. Section III. GUNSHOT WOUNDS. In modern times, the proportion of wounds and injuries of the head received in action has always been large. In the late war, the ratio of such injuries to the total number of casualties was especially great, because the men frequently fought under cover, and many of the engagements were of the nature of siege operations. More than twelve thousand gunshot wounds of the head must be discussed. They will be classified, with many sub- divisions, into those affecting the scalp only, those attended with injury to the skull, and those implicating the encephalon. Gunshot Wounds of the Scalp.— T he number of such cases is so great that it is only practicable to present a numerical statement, supplemented by details of the fatal and complicated cases. Table TII. Hesults of Several Thousand Seven Hundred and Thirty-nine Cases of Gunshot Wounds of the Scaljp reported during the War of the Uchellion. Patient.s. P "5 P V. R. C. 1 Resigned. Dismissed.* 1 Leave of ab- 1 sence. ! Discharged. 1 Furloughed. 1 Deserted. Transferred to i Gen’l Hospital. ! Paroled. Exchanged. Released on oath. Unknown. Total. 11 167 10 10 97 35 7 337 1-2C 3108 127 542 76 261 1427 958 6625 U. S. Enlisted Men (colored) 7 7.5 13 2 4 26 11 138 Citizen Employes, U. S 1 4 5 10 1 5 3 o 6 8 25 Confederate Enlisted Men 17 65 3 118 7 156 6 108 10 114 604 Total 162 3420 127 10 10 97 593 201 275 1609 8 114 10 1103 7739 * The iut'erence from the records is that these ten officers were not dismissed dishonorably, but were stricken from the rolls for failing to comply with orders to report their condition while on leave of absence. GUNSHOT WOUNDS OF THE SCALP. 71 The following fifty-four fatal cases of gunshot wounds of the scalp are reported as uncomplicated. In every instance, the most careful scrutiny has heen exercised to determine if any injury of the cranium, or its contents, was susj)ected by the surgical attendants ; Case. — Private Thomas Arnisti'ong, Co. 1), ‘id Maryland Volunteers, aged 48 years, received a flesh wound of the head, in an engagement before Petersburg, Virginia, July i, 1864, from a conoidal l)all. He was at once admitted to the Hospital of the Second Division, Ninth Corps, thence sent to City Point, and conveyed to the DeCamp Hospital at David’s Island, New York, where he arrived on July 6th. He died on the 14th of July, 1854. Case. — Private James Barry, Co. D, 2d New York Mounted Eifles, aged 30 years, received, in an engagement before Petersburg, Virginia, June 18, 1864, gunshot flesh wounds of the head and arm. He was admitted to the hospital of the Second Division, Eighteenth Corps, and, on June 19th, was sent to the First Division Hospital at Anna))olis, Maryland, where he died, June 22d, 1864. The late Surgeon B. A. Vanderkieft, U. S. V., recorded the case. Case. — Sergeant Harvey F. Beals, Co. C, 59th New York Volunteers, was struck, at the battle of Cold Harbor, Virginia, June 3d, 1864, by a fragment of shell, which caused a flesh wound of the head. He was admitted, on June 8th, to the Columbian Hospital, Washington, D. C., where simple dressings were applied. Death occurred on June 12th, 1864. Case. — Private Horace Bellows, Co. G, 98th New York Volunteei-s, aged 34 years, was wounded, in an engagement at Chapin’s Farm, Virginia, September 29th, 1864, by a conoidal ball, which sevei'ely injured the scalp over the right side? of head. He was admitted to the liospital of the First Division, Eighteenth Corps. On October 2d, he was transferred to the hospital at Fort Monroe, Virginia, and on October 15th, to the White Hall Hospital, near Bristol, Pennsylvania. He died on October 20th, 1864. Assistant Surgeon W. H. Forwood, TP S. A., reported the case. Case. — Private Rupert Carney, Co. C, 28th Pennsylvania Volunteers, aged 38 years, received, in an engagement near Dallas, Georgia, May 25th, 1864, a slight gunshot scalp wound of the back of the head. He was admitted to the hospital of the Second Division, Twentieth Corps, and, on June "2d, was transferred to the hospital at Chattanooga; thence, on June 11th, to Hospital No. 1, Nashville, Tennessee, where he died, on June 15th, 1864, from the effects of the wound. Case. — Corporal Win. G. Carr, Co. G, 13th New Hampshire Volunteers, aged 40 years, received, in a skirmish, on !May 13th, 1864, a wound of the scalp, from a fragment of shell striking over the left aye, and making a ragged wound an inch and a half in length. He was sent to the hospital at Point Lookout, Maryland, and died on June 22d, 1884. Case. — Private Frank Carter, Co. F, 17th New .York Volunteers, aged 18 years, was wounded, in an engagement before Petersburg, Virginia, June 17th, 1864, by a fragment of shell, which cut the scalp near the vertex. He was, on the same day, admitted to the hospital of the Second Division, Ninth Corps, and, on June 19th, sent to the Hospital at Annapolis. The wound was ilressed with dry lint, sprinkled with opium. ’The patient died July 7th, 1864. Case. — Lientemmt John K. Clemm, Co. K, 3d Maryland Volunteers, received at the battle of Chancellorsville, Virginia, May 3d, 1863, a slight gunshot flesh wound of the head. He w'as admitted to the field hospital of the First Division, Twelfth Corps. He died on May 22d, 1863. Surgeon A. Chapel, U. S. V., recorded the case. Case. — Private Jackson Clifton, Co. D, 107th Illinois Volunteers, aged 22 years, received, at the battle of Fraidilin, Ten- nessee, November 29th, 1834, a shell wound of the light side of the scalp. Ho was admitted, on December 1st, to Hos|)ital No. 3, Nashville, Tennessee, where simple dressings were applied. On December 2d, he was transferred to the Jefferson Hospital, Jeffer- .sonville, Indiana, where he died, on December 17th, 1864, from the “effects of wound.” Case. — Private William Coakley, Co. K, 28th Massachusetts Volunteers, aged 40 years, received, in an engagement before Petersburg, Virginia, June 16th, 1864, a lacerated wound of the scalp from a fragment of shell. He was admitted to the hospital of the First Division, Second Corps, and thence sent to the First Division Hospital at Annapolis, Maryland, which he entered on June 20th. Simple dressings were applied to the wound. The patient died on June 28th, 1864. . Case. — Private Stephen Colledge, Co. E, 2d Pennsylvania Aitillery, aged 33 years, received, in an engagement before Petersburg, Virginia, June 18th, 1864, a gunshot wound of the right side of the scalp. lie was, on the next day, admitted to the hospital of the Eighteenth Corps, and on June 21st, was sent to the Chesapeake Hospital, near Fort Monroe, where he died on July 17th, 1864. Assistant Surgeon E. McClellan, U. S. A., records the case. Case. — Private Martin Cornell, Co. H, 7th Rhode Island Volunteers, aged 33 years, received, at the battle of Spottsyl- v'ania Court House, Virginia, May l‘2th, 1864, a gunshot wound of the integuments of the forehead, over the right eye. He was, at once, admitted to the hospital of the Second Division, Ninth Corps. On May 16th, he was sent to the Ilarewood Hospital, Washington, D. C., and, on May' 18th, was transferred to the First Division Hospital, Annapolis, Maryland, where he died, on June 1st, 1854. Tlie late Surgeon B. A. Vanderkieft, U. S. V., recorded the case. Case. — Private Albert L. Curtis, Co. D, 17th Maine Volunteers, aged ‘20 years, was .struck, near Petersburg, Virginia, June 17th, 1834, by a fragment of shell, which caused a flesh wound of the head. He was admitted to the hospital of the Third Division, Second Corp.s, and thence, on the 21st, conveyed to Wiushington, D. C., to the Lincoln Hospital. On the ‘27th, he was sent to Cony Hospital, at Augusta, Maine. Death occurred on August l‘2th, 1864. Surgeon G. Derby, U. S. V., rejiorted the case. Case. — Private Van Buren Danner, Co. II, 87th Pennsylvania Volunteers, aged ‘26 years, was struck, at the battle of Win- chester, Virginia, September 19th, 1864, by a conoidal bull, which produced a lacerated wound of the scalp over the left frontal 72 WOUNDS AND INJURIES OF THE HEAD, eminence. He was admitted to the depot field hospital on the same day. On the 25th, he was sent to the hospital at Sandy Hook, Maryland, and on the 2Gth, he was transferred to the Sixteentli and Filbert Streets Hospital, Philadelphia, lie died on Novem- ber 10th, 1864. Surgeon T. B. Reed, U. S. V., reported the case. Case. — Private John Duett, Co. E, 8th Maine Volunteers, aged 26 years, received in an engagement at Drury’s Bluff, Virginia, May 16th, 1864, a wound of the scalp in the occipital region from a grape shot. He was, on May 18th, admitted to the hospital at Point Lookout, Maryland, where he died on July 4th, 1864. Surgeon A. Heger, U. S. A., recorded tlie case. Case. — Eben L. Farrar, Musician, Co. I, 96th New York Volunteers, aged 19 years, was wounded in an engagment before Petersburg, Virginia, June 23, 1864, by a conoidal ball, which tore the scalp over the parietal bone. He was at once admitted to the field hospital of the Eigliteenth Corps, and, on June 25th, transferred to the Hampton Hospital, Fortress Monroe. Simple dressings were applied to the wound. He died on July 4th, 1864, from the “effects of the scalp wound.” Case. — Private William Finke, Co. I, 13th Indiana Volunteers, aged 25 years, was wounded in an engagement near Bermuda Hundred, Virginia, on May 20th, 1864, by a conoidal ball, which toi’e the scalp. He was admitted to the hospital of the First Division, Tenth Corps; on May 21st, he was sent to flie hospital at Foi't Monroe, and on June 1st, 1864, transferred to the Ward Hospital, Newark, New Jersey, where he died on June 15th, 1864. 'The late Surgeon G. Taylor, U. S. A., recorded the case. Case.— Private Leroy W. Freeman, Co. H, 142d Pennsylvania Volunteers, aged 18 years, was wounded in an engage- ment at the South Side Railroad, October 27th, 1864, by a conoidal ball, which struck over the right parietal bone. He was, on October 29th, admitted to the hospital steamer Connecticut, and conveyed to Washington, D. C., where he entered the Emory Hospital on October 30th. Simple dressings were applied to the wound. Death occurred on November 12th, 1864, “from hectic fever.” Surgeon N. R. Moseley, U. S. V., reported the case. Case. — Private L. Garrett, Co. C, 56th Alabama Regiment, was admitted to the prison liospital at Nashville, Tennessee, with a gunshot wound of the scalp. He died on November 5th, 1863. Acting Assistant Surgeon T. G. Hickman reported the case. Case. — Private W. A. Giles, Co. C, 98th Ohio Volunteers, received near Atlanta, Georgia, August 6th, 1864, a gunshot wound of the scalp, and was sent to the hospital of the Second Division of the Fourteenth Corps. He was transferred, on August 24th, to Chattanooga, Tennessee, and died, at Hospital No. 1, on August 29th, 1864. Case. — Private George Graff, Co. E, 32d Indiana Volunteers, was struck by a conoidal musket ball, near Dallas, Georgia, May 26th, 1864, and was received at Chattanooga, Tennessee, on June 3d, with a severe lacerated wound of the scalp. He died June 5th, 1864. Surgeon E. B. Collins, 51st Indiana Volunteers, records the case. Case. — Private George Hall, Co. D, 30th United States Colored Troops, aged 20 years, received, in an engagement before Petersburg, Virginia, J uly 30th, 1864, a shell wound of the scalp. He was, on August 1st, admitted to the hospital for colored troops at City Point, and, on August 14th, was transferred to the Summit House Hospital, Philadelphia, where he died on Sep- tember 5th, 1864. Surgeon J. H. Taylor, U. S. V., reported the case. Case. — Private O. J. Hardin, Co. K, 68th Georgia Regiment, aged 23 years, received at the h.attle of Gettysburg, Penn- sylvania, July 1st, 1863, a gunshot wound of the scalp. He was probably treated in a field ho.spital until July 20th, when he was admitted to the Chimborazo Hospital, Richmond, Virginia, where he died on August 7th, 1863. Case. — Private Daniel C. Harrison, Co. C, 76th Illinois Volunteers, received during the siege of Fort Blakely, Alabama, April 8th, 1865, a severe guilshot wound of the scalp. He was admitted to the field hospital of the Second Division, Thirteenth Corps, and, on April 11th, was ordered to be transferred to the St. Louis Hospital, New Orleans, but died on April 14th, 1865, on tlie journey. Surgeon O. Peabody, 23d Iowa Volunteers, records the case. Case. — Private John Holmes, Co. C, 98th Ohio Volunteers, was struck over the occipital region by a conoidal ball, at Atlanta, Georgia, August 6th, 1864. At the hospital of the Second Division, Fourteenth Corps, and at the Chattanooga Hospital, the injury was regarded as a simple laceration of the scalp. He died at Chattanooga, August 18th, 1864. Case.— Private David J. Huganer, Co. K, 6th New York Heavy Artillery, aged 42 years, was wounded, at Cold Harbor, Virginia, May 30th, 1864, by a conoidal ball, which caused a wound of the scalp on the back of the head. He was admitted to the hospital of the Third Division, Fifth Corps; on June 3d, sent to the Stanton Hospital, Washington, D. C., and, on June 21st, transferred to the McDougall Hospital, New York, where he died, on October 5th, 1864, from “e.xhaustion following gunshot wound.” Assistant Surgeon S. H. Orton, U. S. A., reported the case. Case. Private James Ireland, Co. K, 21st Connecticut Volunteers, aged 18 years, received a gunshot wound of the scal)i at the battle of Cold Harbor, Virginia, June 3d, 1864. He was, on June 6th, admitted to the Mount Pleasant Hospital, Wash- ington, 1). C., and, on June 12th, transferred to the McClellan Hospital, Philadelphia, where the injury is diagnosed as gunsliot flesh wound of right cheek. He died on June 16th, 1864. The late Surgeon Lewis Taylor, IT. S. A., reported the case. Case.— Private Andrew Jackson, Co. G, 5th Texas Regiment, was wounded, at the battle of Gettysburg, Pennsylvania J uly 3d, 1883, on the right side of the scalp, by a gunshot projectile. He was admitted to the Seminary Hospital, where he died on July 23d, 1863. Surgeon Henry Janes, U. S. V., recorded the case. Case. Private Jahez Johnson, Co. A, 29th Virginia Regiment, was wounded and made a prisoner in the retreat of the Confederate army from the lines of Petersburg, in April, 1865. He was admitted, on April 17th, to the hospital at Point of Rocks, with what appeared to be a lacerated gunshot wound limited to the scalp. Ho died on April 24th, 1865. FATAL GUNSHOT WOUNDS OF THE SCALP. 73 Case. — Private Wui. A. Johnson, Co. C, 24th Kentucky Volunteers, was wounded in tlie scalp, by gunshot, at Resaca, Georgia, May 14th, 1864. He was sent to Chattanooga, Tennessee, and died on the day of liis admission to Hospital No. 1, May 20th, 1864. Surgeon Francis Salter, U. S. V., reported the case. Case. — Sergeant Francis M. Jones, Co. F, 36th Indiana Volunteers, aged 28 years, I’eceived, in an engagement at Marietta, Georgia, June 23d, 1864, a severe gunshot wound of the scalp. He was admitted to the hospital of the First Division, Fourth Corps, and, on June 27th, was sent northward. On July 1st, 1864, he entered Hospital No. 1, Nashville, Tennessee, and died, on .July 12th, 1864, “li’pm wound.” Surgeon B. B. Breed, U. S. V., reported the case. Case. — Private Gideon M. Jones, Co. B, 25th Ohio Volunteeis, aged 43 years, was wounded, in an engagement at Honey Hill, South Carolina, November 30th, 1864, by a musket ball, which caused a scalp wound of the occipital region. Fie was, on the following day, admitted to the hospital at Hilton Head. Simple dressings were applied; but death took place on January 14th, 1865, “from wound.” Assistant Surgeon C. T. Reber, U. S. V., reported the case. Case. — Private Lewis Kumpf, Co. D, 12th Missouri Vol«nteers, aged 40 years, received, at the battle of Resaca, Georgia, May 14th, 1864, a gimshot scalp wound of the left side of the head. He was, on the same day, admitted to the hospital of the First Division, F'ifteenth Corps; on May 23d, was sent to the fiield hospital, Chattanooga, Tennessee, and, on May 25th, trans- ferred to Hospital No. 1, Nashville, Tennessee, where he died on June 5th, 1864. Case. — Private Chauncey C. Moore, Co. D, 42d Illinois Volunteers, received, at the battle of Chattanooga, Tennessee. November 24th and 25th, 1863, a gunshot wound of the scalp of the right side of the head. He was treated, for a few days, in a field hospital, and, on December 1st, was admitted to the general hospital at Chattanooga. He died on December 18th, 1863. Case. — Corporal S. B. Mortes, Co. K, 1st South Carolina Regiment, was admitted to the Jackson Hospital, Richmond, Virginia, May 15th, 1864, Svith a gunshot wound of the scalp. He died on May 24th, 1864. Di'. Wellford, C. S. A., recorded the case. Case.— Piivate .John Nicholson, Co. D, 56th Massachusetts Volunteers, aged 18 years, i-oceived, at the battle of the Wil- derness, May 6th, 1864, a gunshot wound of the scalp, over the frontal bone. He was, on M.ay 14th, admitted to the Columbian Hospital, Washington, D. C., where simple dressings \vere applied. He died on May 30th, 1864. Reported bj' Surgeon T. R. Crosby, U. S. V. Case. — Private Lewis Noble, Co. C, 73d Ohio Volunteers, received, at the engagement at Tunnel Hill, Georgia, July 20th, 1864, a gunshot fiesh wound of the head. He was sent from the hospital of the Third Division, Twentieth Corps, for transfer to the rear, and died on his way to Chattanooga, July 25th, 1864. Case. — Corporal Lawrence C. Pepoon, (10th Sharpshooters,) 00th Ohio Regiment, aged 21 years, received in an engage- ment before Petersburg, Virginia, July (ith, 1804, a gunshot wound of the head, obliquely across the occipital protuberance. I'he bone was apparentlj^ uninjured. He was admitted to the hospital of the Third Division, Ninth Corps, where simple dressings were applied to the wound. On July 15th, he was sent to theFilbertStreetllospital, Philadelphia, when death occurred on.Iidy 24th, 1864, from “the effects of the wound.” Assistant Surgeon S. A. Storrow, IT. S. A., reported the case. Case. — Private Michael Raher, Co. D, 44th Ohio Volunteers, was struck hy a gunshot projectile at Lewisburg, Virginia, May 23d, 1862, receiving a wound of the integuments over the os frontis without any injury to the bone. He was admitted to the Washington Park Hospital, Cincinnati, Ohio, on June 16th, and died on .June 21st, 1862. Reported by Dr. ,J. B. Smith. Case. — Private Chauncey Reeves, Co. F', 19th Michigan Volunteers, at Resaca, Georgia, May 14th, 1864, was struck by a musket ball, which produced a lacerated wound of the left side of the scalp. He was treated at the hospital of the Third Division, Twentieth Corps. He died on klay 16th, 1864. Recorded by Surgeon W. C. Bennett, U. S. V. Case. — Private Albert A. Roaks, Co. H, 21st Kentucky Volunteers, aged 36 years, was wounded in an engagement near Marietta, Georgia, June 26th, 1864, by a conoidal musket ball, which caused a flesh wound of the head. He was admitted to the hospital of the First Division, F'ourth Corps, and, on the 1st of July, w.as sent to Hospital No. 1, Nashville, Tennessee, but was transferred, on .July 6th, to the .Jefferson Hospital, Jeffersonville, Indiana. Death ensued .July 20th, 1864. Case.— Private James Rowley, Co. C, 4th New York Cavalry, aged 17 yeai’s, received in an engagement near Charles- town, Virginia, August 29th, 1864, a gunshot wound of the scalp. He was, on the following day, admitted to the hospital at Sandy Hook, Maryland, where simple dressings were applied. Death occurred on Sejjtember 1st, 1864, from “effects of wound.” Case. — Private Wm. Sebring, Co. 1, 14th Ohio Volunteers, at Chickamauga, September 19th, 1863, received a lacerated gunshot wound of the left side of the scalp. He was taken to the hospital of the T’hird Division, J'^ourteenth Corps, and thence to the Chattanooga Hospital, where he died on October 9th, 1863. Surgeon Israel Moses, U. S. V., reported the case. Case. — Sergeant Nelson I'. Steinhour, Co. H, 4th New Hampshire Volunteers, aged 23 years, received in an engagement before Petei-sburg, Virginia, June 30th, 1864, a gunshot wound of the scalp. He was admitted, on .July 3d, to the hospital at J’ort iMonroe. Irritative fever followed, and the patient died from exhaustion, on July 10th, 1864. Case. — Corporal William A. Stewart, Co. B, 15th Ohio Volunteers, aged 21 years, received at the battle of Nashville, Tennessee, December 15th, 1864, a simple flesh wound of the scalp. He was admitted to the hospital of the Third Division, J'^ourth Corps, was thence transferred to Hospital No. 1, Nashville, Tennessee, and, on December 20th, sent to the hospital at Jeffersonville, Indiana, where he died on January 24th, 1865, from the “effects of tlie wounil.” 10 74 WOUNDS AND INJURIES OF THE HEAD Case. — Private John Stringer, Co. G, Cth U. S. Colored Troops, received, at Wilmington, North Carolina, February 19th, 180.5, a slight lacerated wound of the scalp by a musket ball. At the hospital for Colored Troops, the injury was regarded as trivial, yet death followed from the effects of the wound on February 2Gth, 1805. Recorded by Surgeon D. W. Hand, U. S. V. C!ase. — Private William Tait, Co. F, 100th Pennsylvania Volunteers, aged 40 years, received, at the battle of Spottsyl- vania, Vii’ginia, May 12th, 1804, a gunshot wound of the scalp. He was admitted to the hospital of the First Division, Ninth Corps. On May 15th, he was sent to the Mount I'leasant Hospital, Washington, I). C., and, on IMa}' 19th, to the McClellan Hospital, Pliiladelphia, where he died on May 28th, 1804. Surgeon Lewis Taylor, U. S. A., reported the case. Case. — Private David Titus, Co. M, 1st New Jersey Caviilry, aged 19 years, received, at the battle of the Wilderness, Virginia, May 5th, 1804, a gunshot wound of the scalp, over the left temporal region. On May 12th, he was admitted to Mount Pleasant Hospital, Washington, D. C., and on June 10th, transfeiTod to DeCamp Hospital, New York Harbor, where he died on .Tune 21st, 1804. Assistant Surgeon Warren Webster, II. S. A., reported the case. Case. — Lieutenant John Van De Sande, Co. B, 115th New York Volunteers, aged 31 years, received, in an engagement near M.alvern Hill, Virginia, August ICth, 1804, a severe gunshot wound of the scalp. He was, on August 17th, admitted to the hospital at Foit Monroe, Virginia, where he died on September 3d, 1804. Assistant Surgeon E. McClellan, U. S. A., reported the case. Case. — Private Jackson IV. Vorhees, Co. 1, 27th Michigan Volunteers, aged 38 years, received, at the b.attle of Cold Har- bor, Virginia, June 3d, 1804, a gunshot flesh wound of the left tem]>le. lie was, on June 8th, admitted to the hospital of the Third Division, Ninth Corps, and on .Tune 14th, to the Second Division Hospitiil at Alexandria. Simple dressings were .applied. Death occurred on .Tune 28th, 1804. Surgeon T. Rush Spencer, U. S. V., I’epoj'ted the c.ase. Case. — Private James Waller, Co. B, 1st North Carolina Regiment, received a very slight gunshot wound of the scalji, at the battle of Gaines’s Mills, Virginia, June 27th, 1602. He was admitted to Ilow.ard Grove Hospital, near Richmond, Virginia, and died July 1.5th, 1802. Surgeon C. D. Rice, P. A. C. S., recorded the case. Case. — Private Ezekiel Wimmer, Co. C, 30th Illinois Volunteers, aged 22 years, received, at the battle of Fr.anklin, Ten- nessee, November 30th, 1804, a gunshot wound of the scalp. Ho was, on the following d.ay, admitted to Hospital No. 1.5, Nash- ville, and, on December 3d, sent to the .lefferson Hospital, Jeffersonville, Indiana, where he died, on December 17th, 1804, from “ fleets of wound.” Surgeon M. Goldsmith, U. S. V., recorded the case. Case.— Private Win. G. Young, Co. G, 41th Illinois Volunteers, aged 24 years, receiv'ed, at Marietta, Georgia, .Tune 20th, 1804, a gunshot W'ound of the scalp. He w'as admitt(‘d to the hospital of the Second Division, Fourth Corps, on the following day, .and transferred to Chattanooga, on .Tuly 2d, and di(‘d on .Julj' 3d, 1804. Assistant Surgeon C. C. Byrne, U. S. A., reported the case. Case. — Sergeant W. H. Zimmerman, Co. E, 11th Pennsylvania Volunteers, .aged 25 ye.ars, at the battle oj' the Wilderness, Vii’ginia, May 0th, 1864, received a scalp wound over the right p.arietal region, from a musket ball, which lodged beneath the integument. The missile was extracted on the field, and the jiatient was sent to the re.ar, .and conveyed finally to Washington, D. C., entering Armory Square Hospital on May 26th. He died on June 20th, 1.864. Nine patients, witli gunshot wounds of the sc in the left parietal region. He was admitted into No. 12 hospital, at Richmond, on December Kith. Symptoms of inflammation of the Itrain made their appearance, and several convulsions fol- lowed. The scalp was shaved, and cold lotions were applied, and mercurials were administered. He died January 4th, 1863. Surgeon W. H. Thom, C. S. A., reports the case. Case. — Corporal John Kealey, Co. A, 99th Pennsylvania Volunteers, aged 21 years, received, while on the picket line before Petersburg, Virginia, September 12th, 1864, a gunshot scalp wound of the vertex, from a conoidal musket ball. He was admitted, on September 1.5th, into the field hospital of the Third Division, Second Corps. On September 19th, the patient was sent to field hospital of the Second Corps, and, on the same day, he was transferred to Washington, where, on September 21st, he was admitted into Emory Hospital. Inflammation of the brain set in, and death followed, October 3d, 1864. Surgeon N. R. Moseley, U. S. V., reported the case. Case. — Sergeant Thomas H. Law, Co. K, 5th New Hampshire Volunteers, received, at the battle of Antietam, Maryland, September 17th, 1862, a gunshot wound of the integuments of the forehead. He was admitted to the hospital of the Second Corps, and, on October 5th, w'as sent to the Ladies’ Home Hospital at New York. An abscess of the scalp formed, and menin- gitis ensued, terminating in compression of the brain, coma, and death on October 11th, 1862. Surgeon A. B. Mott, U. S. V., reports the case. Case. — Private S. Lawson, Co. E, 22d Georgia Regiment, received, at the battle of Gettysburg, Pennsylvania, .July 3d, 1863, a gunshot wound of the scalp, and was t.aken to the Seminary Hospital. On July 25th, he was transferred to the West’s Building Hospital, Baltimore, Maryland, where he died on September 6th, 1863. Case. — Private J. A. Murphy, Co. B, 49th Virginia Regiment, aged 30 years, received, at the battle of Gettysburg, Penn- sylvania, .July 3d, 1863, a gunshot wound of the right side of the scalp. He was, on July 6th, admitted to Hospital No. 1, Fred- ei ick, Maryland, on July 7th, transfeiTcd to Annapolis, probably for exchange, and on August 1st, 1863, he was admitted to a Confederate hospital, at Petersburg, Virginia, where he died, on August 18th, 1863, of meningitis. Case. — Private Hugh O’Donnell, Co. C, 29tli Pennsylvania Volunteers, aged 24 years, received, at the battle of Atlanta, Georgia, .July 20th, 1864, a severe gunshot wound of the scalp. He was admitted into the hospital of the Second Division, Twen- tieth Corps, and thence sent to Hospital No. 2, at Chattanoog.a, Tennessee,- on July 25th. He was transferred, about the 1st of August, to Nashville, and thence, within a few wei'ks, sent to the Satterlee Hospital in Philadelphia. Death supervened on August 31st, 1864. Case. — Private Duncan Stone, Co. C, 1st North Carolina Battery, received a wound of the right side of the scalp hy a conoidal musket ball. He was admitted into the Pettigrew Hospital, Raleigh, North Carolina, on March 23d, 1865. Simple dressings were used. Meningitis supervened, and the case terminated fatally on March 29th, 1865. Surgeon E. Burke Hay- wood, C. S. A., records the case. COMPLICATED GUNSHOT WOUNDS OF THE SCALP. 77 Case. — Private Nicholas Strayer, Co. C, 205th Pennsylvania Volunteers, aged 30 years, received, in an engagement before Petersburg, Virginia, April 2d, 1865, a gunshot wound of the scalp above the left ear. He was admitted to the hospital of the Third Division, Ninth Corps, and, on April 4th, was sent to the Lincoln Hospital, Washington, D. C., where he died on May 12lh, 1865, from inflammation of brain. Assistant Surgeon J. C. McKee, U. S. A., records the case. Case. — Private Henry IVarnei', Co. B, 1st IMichigali Volunteers, aged 29 years, was wounded near Petersburg, Virginia, July 24th, 1864, by a fragment of shell, which caused a severe wound of the scalp. He was admitted to the hospital of tlie First Division, Fifth Corps, and thence sent to City Point, where he remained under treatment until the 6th of August. He was then transferred, by steamer, to the De Camp Hospital at David’s Island, New York Harbor, where death residted on August 20th, 1864. Case. — Private John Warner, Co. D, 4th New Jersey Volunteers, aged 26 years, received, at the battle of the Wilderness, May 6th, 1864, a gunshot w ound of the scalp, by a conoidal musket ball. He was taken to the hospital of the First Division of the Sixth Corps, and transferred to the Finley Hospital, at Washington, on May 11th; from thence he was sent to Philadelphia, and admitted to the Satterlee Hospital on May 18th. On Blay 28th, he was attacked by a chill, attended by a violent pain in the head, and symptoms of cerebral iutlammation. The case terminated fatally on Blay 29th, 1864. Case. — Corporal James E. White, Co. A, 3d New Hampshire Volunteers, aged 33 years, received, in an engagement near James’s Plantation, Virginia, Blay 20th, 1864, a gunshot wound of the scalp from a conoidal musket ball. He was admitted into the field ho! ]Ital of the Tenth Corps on the same day, and a day later was transferred to the Hampton Hospital at Fort Blonroe. On June li.t, the })atie!it was sent to the Ward Hospital, at Newark, New Jersey. Congestion of the brain supervened, and death resulted on July 14th, 1864. The late Assistant Surgeon J. T. Calhoun, U. S. A., recorded the case. In eight fatal cases of gunshot wounds of the scalp, it may be inferred, froiii the nature of the prescriptions, that some form of encephalitis supervened and induced fatal results ; but the precise features of the secondary complications were not reported : Case.— Private John Aufterheide, Co. B, 6th Ohio Volunteers, received, at the battle of Chickamauga, Georgia, Septem- ber 19th, 1863, a severe gunshot flesh wound of the head. He was, at once, admitted to the hospital of the Second Division, Twenty-first Corps, and, on the next day, sent to the General Hospital at Chattanooga, Tennessee, where he died, on September 22d, 1863. Surgeon A. J. Phelps, U. S. V., recorded the case. Case.— Private A. L. Cook, Co. E, 16th Connecticut Volunteers, received, in the engagement at Plymouth, North Caro- lina, April 20th, 1864, a gunshot wound of the scalp. He died on May 9th, 1864. Surgeon D. G. Rush, 101st Pennsylvania Volunteers, recorded the case. Case.— Private Isaac Hamlin, Co. F, 101st Illinois Volunteers, received, near Dallas, Georgia, May 25th, 1864, a slight gunshot wound of the head. He was admitted into the field hospital of the Third Division, Twentieth Army Corps, on the same day, and, on Blay 30th, he was sent to Chattanooga. He died on June 16th, 1864. Case. — Private J. TI. Hatley, Co. D, 27th North Carolina Infantry, received, in action, a gunshot wound of the scalp. He was admitted into the Mooi-e Hospital at Richmond, Viiginia, December 20th, 1863, and died on December 22d. Surgeon Otis F. Blanson, C. S. A., recorded the case. Case. — Private J. Hinton, Co. C, 28th Alabama Regiment, was wounded and made a prisoner at the battle of Chattanooga, and was admitted, on November 23d, 1863, to Hospital No. 4, Chattanooga, Tennessee, with a gunshot scalp wound over the forehead. He died on December 15th, 1863. Surgeon Francis Salter, U. S. V., reports the case. Case.^ — Private Clarence R. Smith, Co. A, 94th New York Volunteers, was admitted to the Patent Office Hospital, Wash- ington, D. C., on September 21st, 1862, with a gunshot wound of the scalp. He died on October 1st, 1862. Assistant Surgeon J. J. Woodward, U. S. A., recorded the case. Case. — Private Hiram Voiles, Co. F, 70th Indiana Volunteers, received, at the battle of Resaca, Georgia, May 15th, 1864, a slight gunshot wouml of the right side of the scalp. He was admitted to the hospital of the Third Division, Twentieth Corps, and, on Blay 20th, was sent to the general fi Id hospital at Resaca, where he died, on May 24th, 1864. Assistant Surgeon BI. C. Woodworth, U. S. V., recorded the case. Case. — Private Bladison Wilman, Co. D, 15th Iowa Volunteers, aged 26 years, received, at the battle of Shiloh, Tennes- see, Aj)ril 6th, 1862, a slight gunshot wound of the scalp. He died on June 1st, 1862. Surgeon Samuel B. Dawes, 1.5th Iowa Volunteers, reported the case. Erysipelas . — The proportion of cases in which erysipelas supervened after gunshot wounds limited to the integuments of. the cranium, was by no means large. But twenty- two cases were reported, of which eight terminated fatally. It is highly probable that this complication was present, in a mild form, in many of the cases reported without commentary as “returned to duty but was seldom of such gravity as to be made the subject of special report. The few exceptions are here noted : 78 WOUNDS AND INJURIES OF THE HEAD, Case. — J. IS. BrUloc, Co. C, 2titli Virginia liegimont, aged IW years, received, on July 17th, 18(54, a gunshot wound of the scalp, just above the right eye. During the progress of the ease erysipelas supervened, but it was checked, and, on July 30th, the patient was reported as convalescing. Surgeon P. F. Brown, C. S. A., I'ecords the case. Case. — I’l ivate Charles Ferry, Co. B, 72d New York Volunteers, aged 37 years, received, in the Peninsular campaign, at JIalvern Hill, July 1st, ISti’J, a shell wound of the occipital region of the scalp. He was adi^itted to Division No. 1 Hospital, at Annapolis, IMaiyland, from the Steamer Kennebec, July 5th, 18(5‘J. A severe attack of erysipelas supervened, from which the jiatient recovered, and was returned to duty on October 11th, 18(52. Acting Assistant Surgeon Arthur Rich recorded the case. Case. — Pjivate Henry T. Frazell, Co. 15. (ith iMissouri Volunteers, received in front of Vicksburg, Mississippi, May 22d, 18(53, a gunshot wound of the scalp in the right teni[ioral region. He was received on board the hospital steamer K. V. Wood, from Chickasaw Bayou, on the 8th of June, and transferred to Memphis, Tennessee, whei e, on the same day, he was admitted to llnion Hospital. On the morning of the 2yth, the wound was attacked hy erysipelas, which soon extended over the entire scalp and face. The disease yielded readily to ti-eatment, and, on Jidy 7th, the patient was reported as very neaily free of the disease. On (he 22d of J uly, he had so completely recovered as to be able to return to duty. The case is reported by Surgeon J. D. Brum- ley, U. S. V. Case. — Private T. A. GaUayhcf, Co. C, 10th Louisiana, was w ounded at the battle of Gettysburg, Pennsylvania, July 3d, 18(53, by a musket ball, which entered the scalp to the left of the median line, near the suj)orior lidge of the occiput. The missile passed forw ard, and downward behind the ear, and lodged about the middle of the lower jaw. He also received a gunshot wound of the ankle. Tlie wounds w’ere dressed in a held hos|)ital, and thence he was sent to Camj) Letterman Hospital at Gettysburg, where he was admitted on July 27th. Eiysipelas supervened, which, hy appropriate treatment, was subdued, and, at the date of his transfer to Baltitnori‘, the patient was doing well. He was admitted, on October (ith, to West’s Building Hospital, at Balti- more, Maryland, where ho remained until November 12th, 1853, on which date he was paroled. Case. — Fiist Sergeant Samuel B. Gray, Co. I, 123d Illinois Volunteers, in an engagement near Milton, Tennessee, March 2(lth, 18(53, received a gunshot scalp wound. He was admitted into Hospital No. 1, at Murfreesboro, March 21st, and transferred thence to Nashville, and admitted, on May 22d, in Hospital No. 23. He remained here utitil August 1st, when he was sent to Louisville, anil adnutted into Hospital No. 7. On September 3d, he was sent to Hospital No. 19, where erysipelas supervened. Simple dressings were used. He was discharged from service October 13th, 18(53, on account of a scrofulous abscess. The case is rejiorted by Assistant Surgeon E. O. Brown, 26th Kentucky Volunteers. Case. — Sergeant K. M. Harris, Co. F, 3d Tennessee Infantry, aged 24 years, received at the battle of Kenesaw Mountain, Georgia, June 30th, 1864, hy a conoidal ball, a wound of the scalp over the right temple. He was admitted, on July llth, to Holston Hospital, at Knoxville, Tennessee. The wound became affected with erysipelas, which was subdued, and the patient was furloughed on the 26th of October. On November 18th, he was admitted to Asylum Hospital at Knoxville, where he remained until February 4th, 1865, when he was returned to duty. The case was reported by Acting Assistant Surgeon S. L. Herrick. Ca.se. — Sergeant John MePeake, Co. B, 82d New York Volunteers, received, at the battle of Antietam, Maryland, Sep- tember 17th, 1862, a gunshot wound of the iutegunients of the forehead. He was admitted to the regimental hospital, and, on November 21st, was sent to hospital at Camp I’arole, Annapolis, Maryland. Erysipelas of a severe character supervened, but the patient recovered, and was discharged from the service on February 23d, 1863. Surgeon James Norval, 79th New York State Militia, recorded the case. Ca.se. — Private J. L. Means, Texas Regiment, received, in the assault on Fort Douelson, Tennessee, February 15th, 1862, a sliglit wound of the scalp, over left jiarietal region, by a musket ball. He was conveyed to a Confederate hospital in Nashville. Erysipelas set in, on the tenth day lifter the reception of the injury, and extended over the entire head and face. Tincture of iodine was applied locally, and general supporting treatment was eni|)loyed. He rapidly recovered, and was discharged from the hospital about March 2()th, 1862, for duty. Ca.se. — Private .7. L. Smiley, Co. E, 12th Alabama Infantry, aged 19 years, received, in the assault on Fort Steadman, Virginia, March 25th, 1865, a gunshot wound of the occipital region, by a conoidal musket ball. He was admitted into the Wash- ington Street Ilosiiital, at Petersburg, Virginia, on the same day. Erysipelas sujiervened. The patient was made a prisoner and transferred to the Hanijiton Hospital, at Fort Monroe, May 17th, and on May 25th, 1865, he was sent to the Military Prison. Assistant Surgeon B. F. Pope, 10th New York Artillery, reports the case. Case. — Private William 11. Smith, Co. 1, 99th Pennsylvania Volunteers, aged 18 years, received, in an action on the South- side Railroad, Virginia, about April 7th, 1865, a gunshot wound of the right parietal region. He was admitted into the field hos- pital of the Third Division, Second Corps. Simple dressings were applied. On April 12th, he was admitted into the Second CoT’[)S field hospital, at City Point, whence he was transferred, on April 18th, to Finley Hosfiital, Washington. On April 21st, erysipelas attacked the scalp and face. Tincture of iodine, and lead and opium washes, and poultices were used. He was admitted into Mower Hosjiital, Philadelphia, May 19th, and on July 19th, 1865, he was discharged from service. Case. — Private F. M. Streeter, Co. G, 42d Mississippi Infanjry, received a gunshot wound of the scalp. He was admitted, oil .luly 23d, 1863, into the Howard Grove Hospital, Richmond, Virginia. Erysipelas supervened. On September 16th, 1863, he was furloughed. The case is reported by Surgeon C. D. Rice, P. A. C. S. Case. — Private L. H. Taylor, Co. A, 46th Virginia Regiment, was admitted, on July 2d, 1864, to the Howard Grove Hos- pital, Richmond, Virginia, with a gunshot wound of the scalp. Erysipelas supervened; but otherwise the case progressed ftivor- ably, and the patient was furloughed, on July 31st, 1864, for thirty days. Surgeon C. D. Rice, P. A. C. S., recorded the case. COMPLICATED GUNSHOT WOUNDS OF THE SCALP. 79 Another case of erysipelas of the scalp, complicated hy heemorrhage, will be recorded further on among the abstracts of seal}' wounds with haemorrhage. Still another affords an instance of the a}'}''lication of sutures in gunshot lacerations of the scalp: Case.— Private .laiues Paiclianaii, Co. C, (itli Iowa Volunteers, aged 35 years, received at tlie battle of Eesaca, Georgia, May 14th, lSfi4, a lacerated wound of the vertex of the scalp, from a fragment of shell. T'he cranium was laid bare for a distance of two and a half inches. lie was admitted to the field ho?]rital of the Fifteenth Anny Corps, in charge of M. C. Woodworth, Assistant Surgeon U. S. V., on the same day, and the wound was cleaned, the seal]) shaved, and its edges a])proxi- mated by sutures. The wound was then covered with water dressings. The next re])ort is dated May 20th, when it is stated that the wound was tumefied, highly infiamed, sup])urating, and gaping, the sutures having broken out. The wound was cleaned of |)uruh*nt matter, and was dressed tvith stiips of isinglass plaster, and covered hy a compress. On the 21st, there was erysi])elatous inflammation extending fiom the vertex over the forehead nearly down to the eyelid. The wound was dressed with plasters, as before, and strong tincture of iodine was painted over the entire inflamed surface and a border of the sound skin adjacent. On the 22d the erysipelas extended slightly downwards to the face. On the 25th, the inflammation had, iti a great measure, subsided. The jjatient was transferred to the Cumberland Hospital, at Nashville, Tennessee, under the care of t^urgeon C. McDermont, U. S. V., and was treated by simple dressings to the scalp and with purgatives. On June 4th, he was transferred to the Holt IIosj)ital, at Jeflersonville, Indiana, in charge of Surgeon H. P. Stearns, U. S. V. It is stated on the register of this hospital, that the wound was inflicted by a conical musket ball. The patient recovered without further complication, and was returned to duty August 19th, 18C4. Eight cases were reported which terminated fatally in consef}iience of the meningeal inflammation following the invasion of erysipelas ; Case. — Private Lewis Alfiey, Co. K, 22d Indiana Volunteers, received in an engagement at Kenesaw Mountain, Georgia, .Tune 27th, 18G4, a gunshot wound of the seal]). He was admitted to the hospital of the Second Division, Fourteenth Corps, and, on Jidy 1st, was transferred to the Cumberland Hospital at Nashville, Tennessee. He died, July 26th, 1864, “of ery.sipelas, following gunshot wound of scalp.” Assistant Surgeon W. 15. Trull, U. S. V., records the case. Case. — Corporal William Cammire, Co. H, 73d Illinois Volunteers, aged 22 years, was admitted to Hospital No. 19, Nashville, Tennessee, on December 1st, 1864, with a gunshot wound of the left side of the scalp. Erysipelas of the head and face supervened, and the case had a fatal termination on December 4th, 1864. Case.— Private James JS. Fant, Co. B, 17th Mississij)pi Kegiment, was, on May 9th, 1864, admitted to the Howard Grove llos]iit;d, Eiehmond, Virginia, with a lacerated wound of the scalp in the left temporal region, caused by a gra])e shot. On July 8th, erysipelas attacked the wound, and death resulted on July 29th, 1864. iSurgeon T. M. Palmer, C. S. A., records the case. Case. — Private William Jackson, Co. F, 16th Ohio Volunteers, received, at the siege of Vicksburg, Mississij)])i, Decem- ber 28tb, 1862, a gunshot wound of the left side of the seal]). He was conveyed, on the steam transport C’ity of Memphis, to Paducah, Kentucky, and was admitted, on January 8th, 1863, into IIos])ital No. 2. Erysipelas of the seal]) supervened, and death resulted from exhaustion, on February 23d, 1863. At the post mortem examination the liver, spleen, and mesenteric glands were found enlarged. The case was reported by Surgeon II. P. Stearns, U. S. V. Case. — Corporal Francis N. Lewis, Co. E, 18th North Carolina Eegiment, leceivcd, in an engagement before Petersburg, April 1st, I860, a gunshot wound of the scalp. He was, on A])i-il 4th, admitted to the hospital at Fort Monroe, wdiere he died, on April 13th, 1865, of erysipelas. Assistant Surgeon W. D. Wolverton, U. S. A., records the case. Case. — Private Eeinhold Maywold, Co. G, 6th Wisconsin Volunteers, aged 27 years, was wounded, in an engagement at the Southside Eailroad, April 1st, 186.5, by a conoidal ball, which struck over the squamous portion of the left temporal bone. He was, on the following day, admitted to the field hospital of the Fifth Corps, and, on April 4th, was sent to the Lincoln Hos- pital, Washington, 1). C., where he died, on April 24th, 1865, from eiysipelas following gunshot wound of scalp. Case. — Private Fountain McClarry, Co. E, 100th U. S. Colored Troo})s, aged 24 years, received, at the battle of Nashville, December ICth, 1864, a gunshot wound of the scalp, on the back of the head. He was admitted, on the following day, to Hospital No. 16. Simple dressings were applied. Erysipelas supervened, and death followed, on J.anuary 14th, 1865. Case. — Private John Williams, Co. B, 12th New Jersey Volunteers, aged 30 years, received, in the attack on Peters- burg, Virginia, June 17th, 1864, a shell wound of the left side of the seal]). He was admitted, on June 19th, to the hospital of the Second Corps at City Point, and, on June 25th, was sent to the Lovell IIosj)ital, Portsmouth Grove, Ehode Island. Erysipelas supervened, and death occurred on July 7th, 1864. Gangrene . — The contused wounds of the scal}i made by lialls, til ways followed by llio death of a thin layer of tissue, sometimes lead to spreading gangrene, a coiAiilication more common in head wounds with fracture of the skull than in those limited to the seal}). In the latter class, but nine cases of traumatic gangrene were reported, of which four terminated fatally. 80 WOUNDS AND INJURIES OF THE HEAD. Case. — Private Josepli H. Clouse, Co. U, ‘20tli Iiuliana Volunteers, was wounded at the battle of Gettysburg, Pennsyl- vaiua, July 3d, 1863, by a coiioidal ball, which entered just above the frontal eminence of the left side, and made a large flesli wound. He was sent to Philadelphia, and, on July 5th, admitted to the Satterlee Hospital. Cold water dressings were apjjlied until the 11th, when Hax-seed poultices were used. The wound did comparatively well until the 20th, when gangrene appeared. Tincture of the sesquichloride of iron was given, and applications of nitric acid, followed by emollient dressings, were made for a few days, when the sloughs came away, and the wound commenced to heal. On, the 24th, the edges were ai)proximating. About a square inch of the bone was visible, one-half of which was denuded of its periosteum. The patient was furloughed on August 2d, 1863; returned to his regiment, and wiis, on December 22d, 1863, transfeiTed to Co. F, 20th Indiana Kegiment, reorganized. Case. — Private William rad(jct, Co. B, 1st Florida Battery, was admitted, on J une 4th, 1864, to Howard Grove Hospital, Richmond, Virginia, with a gunshot wound of the scalp over the left temponil bone. Gangrene attacked the wound, but was readily checked, and on July 23d the patient was furloughed for sixty days. Case. — Private Horace Garrcjuis, Co. E, 8th Connecticut Volunteers, aged 20 years, received, in an engagement before Petersburg, Viiginia, May 7th, 1864, a gunshot wound of the scalp. He was, on May 9th, admitted to the Flampton Hospital near Fort Monroe, and, on May 18th, transferred to the Mower Hospital, Philadelphia. On May 30th, the wound commenced to slough. Bromine was applied, and afterwards fla.x-seed poidtices, and on June 15th, healthy granulations set hi. On July 11th, the patient was sent to the Knight Hospital, New Haven, Connecticut, and on October 11th, 1864, he was returned to duty. Case. — Private John K. Kittredge, Co. 1, 93d New York Volunteers, aged 20 years, was wounded at the battle of the Wilderness, Virginia, May 5th, 1864, by a conoidal ball, which passed across the vertex of the cranium from left to right, causing a scalp wound two inches in length. He was admitted to the hospital of the Third Division, Second Corps; on May lOth, sent to the Carver Hospital, Washington, D. C., and, on May 1.5th, transferred to Mower Hospital, Philadelphia. On .June 14th, the wound began to slough; poultices were applied, and on June 18th the sloughing had ceased. Kittredge was returned to duty on October 4th, 1864. Case. — Private W. I. Watson, Co. D, 26th Georgia Cavalry, received, on October 27th, 1864, a gunshot wound of the scalp. He was admitted into the second division of the Jackson Hospital, Richmond, on the same day. Gangrene supervened. He recovered, and was furloughed March 24th, 1865. The following cases of sloughing after gunshot wounds of the scalp, terminated fatally ; Case. — Private Daniel L. Dougherty, Co. H, 55th Pennsylvania Volunteers, aged 27 years, was wounded before Peters- burg, Virginia, June 16th, 1864, by a conoidal ball, which injured the scalp and the left shoulder. He was, on the following ilay, admitted to the hospital of the Eighteenth Corps, at Point of Rocks, Virginia, and, on June 19th, was sent to the Hampton Hospital, Fort Monroe, where simple dressings were applied to the wound. Death occurred on July 15th, 1864, from gangrene and exhaustion. Assistant Surgeon E. McClellan, U. S. A., recorded the case. Case. — Private Patrick Doyle, Co. D, 117th New York Volunteers, aged 36 years, was wounded before Petersburg, Virginia, Juno 15th, 1864, by a fragment of shell, which caused a wound of the scalp. He was treated, for some days, in a lield hospital, and thence, on June 24th, transferred to the Mount Pleasant Hospital, Washington, D. C., and, on June 27th, sent to the Satterlee Hospital, Philadelphia. Gangrene attacked the wound, and the patient died on July 30th, 1864. Case. — Private Irvine Hawkhis, Co. I, 2d New York Artillery, aged 19 years, received, in an engagement at Petersburg, Virginia, June 16th, 1864, a gunshot wound of the occipital region, by a round ball. He was admitted, on the same day, into the held hospital of the First Division, Second Army Corps, and, on the 21st, was sent to the base hospital at City Point. Simple dressings were used. The jjatient was subsequently transferred to Washington, and was received into the Mount Pleasant Hospital on June 27th. He was, a few days later, sent to the Chester Hospital in Pennsylvania. The wounds fell into a sloughing condition, and death resulted from the consequent exhaustion, July 28th, 1864. Surgeon Thomas H. Bache, U. S. V., re]iorts the case. Case. — Corporal William Roth, Co. E, 119th New York Volunteers, aged 28 years, received, at the battle of Gettysbui'g, I’ennsylvanla, July 3d, 1863, a scalp wound in the left parietal region, and also a wound through the left latissimus dorsi muscle. He was conveyed to Philadelphia, and, on July 5th, was admitted to the Satterlee Hospital. Both wounds were gangrenous. Charcoal poultices were applied, after cauterization by nitric acid. On July 26th, the wounds looked healthy; but, on July 29th, excessive diarrhoea supervened, followed by chills and headache, and death occurred on August 2d, 1863. The case is reported by Acting Assistant Surgeon N. Hickman. llcemorrhage.—ln gunshot wounds of the scalp, primary hiemorrhage was very infrequent, but secondary hoemorrhage was not uncommon, and proved, when it occurred, a very troublesome complication. Abstracts will be given of all the cases, twenty-one in number, reported in detail : Case. — Private Thomas Bell, Co. A, 9th Pennsylvania Volunteer Reserves, a paroled prisoner, was admitted to hospital at Annapolis, Maryland, on January 11th, 1863. He had been wounded by a musket ball, which entered the scalp to the right of the occipital protuberance, and, passing forward and slightly upward, emerged at a distance of two inches above the ear. The missile, in its course, cut the occipital artery, from which there was profuse haemorrhage. Sight and hearing were some- OOMPLICATEt) GUNSHOT WOUNDS OF THE SCALP. 81 wliat affected; but, on the date of liis leaving tbe hospital, the patient was doing well. Tie was transferi’cd, on January 21st, 1863, to Pittsburg, Pennsylvania, after which there is no account of him. Surgeon T. A. JlcPai liu, U. S. A., records the case. Case. — Private Burton Fuller, Co. IT, 7th Iowa Volunteers, was wounded, at the battle of Corinth, Jlississippi, October 3d, 18G2, in the right temple. The missile entered on a line with the external canthus of the right eye, severing the temporal artery, and lodged. He was, on October 13th, 1862, admitted to the hospital at Mound City, Illinois, where the temporal artery was ligated. Fuller was discharged from the service on January 13th, 1863. Case. — Private John Hearne, Co. E, lG4th New York Volunteers, was wounded, in an engagement near Suffolk, Virginia, A])ril 24th, 1863, in the right temporal region, the missile dividing the temporal artery, which bled freely. The hsemorrhage was checked by compression, and the patient was sent, on the following day, to the hospital at Hampton, Virginia. On Juno 22d, 1863, he was returned to duty. Case. — Lieutenant A. St. Clair Smith, Co. E, 12th New Hampshire Volunteers, was wounded at the battle of Cold Har- bor, Virginia, June 3d, 1864, by a conoidal musket ball, which cut the scalp over the left ear and severed the temporal artery, which was secured with some difficulty. He was admitted, on June 5th, to the field hospital of the Eighteenth Corps, and thence sent to Washington, D. C., and was treated, at his quarters, at the Avenue House. He was furloughed, on June 11th, 1864, and was finally mustered out with his regiment, on June 21st, 1865. Acting Assistant Surgeon G. K. Smith recorded the case. Case. — Corporal John C. Taylor, Co. D, 5th New Jersey Volunteers, aged 44 years, received, at the battle of Fair Oaks, June 1st, 1862, a gunshot wound of the scalp. He was sent to the Seminary Hospital at Georgetown, D. C., and admitted on June 4th. Profuse limmorrhage occurred, on the same day, from one of the branches of the temporal artery. The main trunk was ligated, just above the zygomatic process. The patient was returned to duty on August 19th, 1862. The case is reported by Acting Assistant Surgeon Josiah F. Kennedy. In six cases of secondary lieemorrliage from gunshot wounds of the scalp, the bleeding was controlled by pressure and by styptics : Case. — Private G. A. Arnold, Co. G, 2d Vermont Volunteers, aged 21 years, was wounded, at the battle of the Wilderness, Virginia, May 5th, 1864, by a conoidal musket ball, wliich caused a wound of the scalp in the right parietal region. He was admitted to the Harewood Hospital, Washington, D. C., and, on May 15th, sent to Mower Hospital, Philadelphia. On the fol- lowing day hmmorrhage occurred fi'om the parietal branch of the temporal artery, which was controlled by compression. On May 31st, the wound had nearly healed, but the patient suffered from headache. He was returned to duty on July 26th, 1864. Case. — Private John Gallager, Co. G, 5th New Jersey Volunteers, aged 25 years, was wounded at the battle of the Seven Pines, Virginia, June 1st, 1862, by a round ball, which struck in the right parietal region, two inches from vertex, laying the bone bare. He was conveyed to Washington, and admitted, on June 4th, into the Seminary Hospital, Georgetown. A haemor- rhage took place fi-om the tempor.al artery on the same day. The patient suffers from occasional attacks of vertigo. On .July 18th, he was transferred to the Union Hotel Hospital, in the same place, and, on July 25th, 1862, was returned to duty. Assist- ant Surgeon Joseph E. Smith, U. S. A., reports the case. Ca.se. — Private Zachariah Hancock, Co. I, 19th Indiana Volunteers, was wounded, at the battle of Gettysburg, Pennsyl- vania, July 2d, 1863, by a buckshot, which entered behind the left ear and lodged. He was, on the same day, admitted to the Seminary Hospital, Gettysburg, and, on July 11th, sent to the McClellan Hospital, Philadelphia. Hajmorrhage, amounting to twelve ounces, occurred on the following day, but was arrested by pressure and a solution of the persulphate of iron. The patient was discharged on Decembei* 3d, 1863. Surgeon Lewis Taylor, U. S. A., records the case. Case. — Private John Lowrey, Co. I, 2d United States Infantry, aged 29 years, was wounded, at the battle of Antietam, ilaryland, September 17th, 1862, in the right temporal region. He was, on September 22d, admitted to Hospital No. 5, Fred- erick, ^Maryland, and, on October 10th, sent to McDougall Hospital, Fort Schuyler, New Yoik Harbor. On October 16th, hmmoiThage occurred from the temporal artery, but was easily controlled by compresses and styptic preparations. The patient was returned to duty on November 4th, 1862. Case. — Private John O'Connor, Co. I, 20th Massachusetts Volunteers, aged 21 years, received, at the battle of Gettysburg, Pennsylvania, July 2d, 1863, a wound of the scalp near the vertex, by a fragment of shell. He was admitted into a field hosj)ital, and, a few days later, was sent to Philadelphia, and admitted, on July 7th, into the Mower Hospital. On July lltli, a consid- erable haemorrhage took place, which was controlled by a compress and styptics. He deserted October 5th, 1863. The case is reported by J. Hopkinson, Surgeon, U. S. V. Case. — Private Henry Schumnghausen, Co. I, Ist Ohio Light Artillery, aged 25 years, was woifnded in the forehead, by a buckshot, in the engagement at Chantilly, Virginia, September 1st, 1862. He was admitted to the Master Street Hospital, Phil- adelphia, on September 3d, 1862. The injury was regarded as slight, but subsequent sloughing caused hmmorrhage from the frontal arteiw on September 10th. The bleeding was readily arrested by continuous pressure and Monsell’s dry salt. The wound healed, and the patient was discharged from the service on January 4th, 1865. In eight cases, the bleeding was successfully treated by ligating the wounded vessel : Case. — Lieutenant Henry Gilmore, Co. A, 17th Vermont Volunteers, aged 32 years, received, at the battle of Spottsylva- ni.a, Virginia, May 12th, 1864, a gimsliot flesh wound of the he.ad. Ho was treatial in a field hospital until May 19th, when he n 82 WOUNDS AND INJURIES OF THE HEAD was sent to the Campbell Hospital, Washington, D. C. On admission, the wound was in a bad condition; the temporal hone was exposed to view, and the tissues were sloughing ami inclined to gangrene. On iMay 21st, limmorrhage occurred from the tem])oral artery. Acting Assistant Surgeon F. W. Kelly, ligated the artery in its continuity. No untoward symptoms occurred. On August 15th, Lieutenant Gilmore was transferred to the Olhcers’ Hospital, at Annapolis, Maryland, and, on St'ptemher Gth, 1864, he was returned to duty. Surgeon A. F. Sheldon, U. S. V., records the case. Case. — I’livate F. C. Ihirtly, Co. G, 49th Virginia Regiment, aged 21 years, was admitted on June 1st, 1864, to Chimbo- razo Hospital, Richmcnd, Virginia, with a gunshot wound of the scalp, received on May 31st, 1864. On June 5th ha-morrhage occurred from the anterior branch of the temporal artery, which was ligated near the expansion of the temporal muscle. On June 39th, the patient was doing well, and, on July 1st, he was furloughed for sixty days. Case. — Piivate Josiah Mullen, Co. A, ICOth Pennsylvania Volunteers, was wounded during the .siege of Knoxville, Ten- nessee, November 30th, 1863, by a conoidal ball, which struck the left side of the head and severed the temporal artery. He was at once admitted to Hospital No. 5, Knoxville, where Surgeon George B. Coggswell, 29th Massachusetts Volunteers, ligated the temporal artery near its oiigin. 'I'he ball was not discovered until December 5th, when it was extracted from beneath the sterno- cleido-mastoid muscle, near the sternal extremity. The patient recovered, was fuiloughed on February 17th, 1864, and finally returned to duty. The case is reported by Surgeon A. M. Wilder, IT. S. V. Case. — I’rivate Ileniy Reese, Co. I, 53d Pennsylvania Volunteers, aged 18 years, was wounded at the battle of Gettys- burg, Pennsylvania, July 2d, 1863, by a shell, which caused a Hesh wound over the right temple. He was, on July'5th, admitted to the Siitterleo Hospital, Philadelphia. On July ICth, haemorrhage, amounting to four ounces, occurred from the temporal artery, which was ligated in the wound. Haemorrhage did not recur, and the patient was returned to duty on December 7th, 1833. The case is reported by Surgeon I. I. Hayes, LT. S. V. Case. — Corporal A. Talniadge, Co. E, 11th New Jersey Volunteers, aged 32 years, was wounded at the battle of Gettys- burg, Pennsylvania, July Sd, 1863, by a conoidal musket ball, which tore the scalp over the left temple for a distance of one by two and a half inches. He was admitted, on July 5th, to Satterloe Hospital, Philadelphia. The wound became gangrenous, and was treated with flaxseed meal and porter poultices. The pain was intense, and the patient was unable to rest ; the wound began to slough, and there was such free bleeding, that on July 14tii the anterior temporal artery was ligated. The slough was grad- ually thrown off, and, on July 23d, healthy granulation commenced. A slight hajmorrhage occurred on July 27th, but was speedily arrested by compression. The jiatient was furloughed on August 1st, 1833, and returned to duty on March 24th, 1834. The case is reported by Surgeon I. I. Hayes, U. S. V. The following patients recovered, also, from secondary haemorrhage treated by ligation, and they were discharged on account of the expiration of their terms of service : Case. — Corporal Henry Kullman, Co. I, 27th Wisconsin Volunteers, aged 25 years, was wounded in an engagement before Petersburg, Virginia, July 30th, 1864, by a conoidal musket ball, which entered anteriorly to the light ear, passed through the pavilion, and emerged just behind the concha. He was at once admitted to the hospital of the First Division, Ninth Corps, and, on August 1st, was sent to the Harewood Hospital, Washington, D. C. On August 14th, haemorrhage, amounting to four ounces, occurred from the temporal artery, which was ligated in its continuity by Surgeon R. B. Bontecou, U. S. V., a ligature being jdaced above and below the wound. Hamiorrhage did not recur. On September 3d, 1864, the patient was sent to the Mower Hospital, Piiiladelphia, and, on May 30th, 1865, was mustered out of service. The case is reported by the operator. Surgeon R. B. Bontecou, U. S. V. Case. — Private Richard Norris, Co. C, 1st United States Cavalry, aged 32 years, was wounded at the battle of the Wil- derness, Virginia, May 8th, 1864, by a conoidal musket ball, which entered in front of the right ear and emerged two inches back of the right mastoid ))rocess. He was admitted into Finley Hos])ital, Washington, D. C., on Slay 11th, 1864. On Miiy 25th, haiuiorrhage occurred from the occipital arteiy, which was ligated by Acting Assistant Surgeon F. G. H. Bradford. The man recovered, and was discharged on July 20th, 1864, on account of the expiration of tenn of service. Surgeon G. L. Pancoast, U. S. V., reported the case. In the following case, recovery ensued after ligation for secondary hsemorrhage, and the patient deserted from hospital : Case. — Private David Jones, Co. B, 1st Massachusetts Volunteers, aged 26 years, was wounded at the battle of Spottsyl- vania, Virginia, May 9th, 1864, by a conoidal musket ball, wliicli entered above and to the left of the left eye, passed in a direct line through the integuments over the temporal region, and emerged four inches from the point of entrance. He was conveyed to the Second Division Hospital at Alexandria, and, on May 21st, was transferred to Mower Hospital, Philadel])hia. The wound was swollen and painful, and bled freely. On May 24th, the temporal artery was ligated in its continuity, in front of the ear, and half an inch below the wound, by Acting Assistant Surgeon S. D. Mar-shall. An attack of erysipelas was checked by local applications of iodine and of lead water. The patient recovered, and was, on July 7th, 1864, sent to the hospital at Beverly, New Jersey, whence he deserted on July 23d, 1864. Two cases of gunshot wound of the scalp, complicated by hsemorrhage, had a fatal termination : Case. — Private Alexander Brown, Co. B, 14th New York State Militia, aged 33 years, was wounded at the battle of the Wilderness, Virginia, May 8th, 1864, by a conoidal musket ball, which entered in front of the left ear, pass(!d do\vnward and backward, and emerged about one inch below the occiput. He was admitted into the field hospital of the Fourth Division, COMPIJCATKD GUNSHOT WOUNUS OF THE SCALP. 83 Fifth Amiy Corps, on tho sanip day, and a few days later sent to Alexandria, and was admitted, on May 12tli, to the Second Division Hospital. Siinj)]e dressings were used. On May 19th, hatmoi'rhage took plaec! from the occipital ai'tery, and, though tempoi'iwily checked, the. arterial bleeding recuiTi'd on the 20th, and, on the 21st; about thirty-eigbt ounces of blood were believed to have been lost altogether. Compression and astringents were the measures unavailingly employed. The patient died on May 21st, 1864. The case is reported by Surgeon T. Eush Spencer, U. S. V. Case. — Private Lewis Jones, Co. C, 115th New York Volunteers, aged 23 years, received, in an engagement at Olustee, Florida, February 20th, 1864, a gunshot wound of the seal]). lie was conveyed to Jacksonville, and thence to Hilton Head, South Carolina, where he entered the hospital on February 25th. On February 27th, haemorrhage amounting to six ounces, occurred from the anterior temporal artery. The vessel was ligated, and h.asmonhage did not recur. On April 20th, he was sent to the hospital at Fort Monroe; on April 2Gth, to the DeCamp Hospital, New York Harbor; and, on September 27th, 1864, to Albany, New Yoik, where he died on October 15th, 1864, from the effects of the wound. Assistant Surgeon M. F. Cogswell, LI. S. V., records the case. Tetanus . — In five of the fatal cases of gunshot wounds of the scalp, tetanus was the cause of death. In every instance, the invasion of this comjilication was ascribed to exposure to dampness, with sudden depression of the temperature of the atmosphere ; Case. — Corporal Charles G. Carpenter, Co. F, 19th Iowa Volunteeis, aged about 32 years, received a wound of the scalp, in the engagement at Morganzia, Louisiana, September 29th, 1863, by a conoidal ball. He was admitted, from the field to St. Louis General Hospital, at New Orleans, on October 4th, 1863, where he was treated by application of simple dressings, and the administration of saline cathartics, and the free use of morphia. On the night of October 7th, the weather became cold and damj), and, on the following morning, the patient manifested symptoms of trismus. The phenomena of acute tetanus rapidly ensued, and the case terminated fatally, on October 11th, 1863. At the autopsy, an extravasation of blood was found beneath the skull, at a point corresponding with the wound of the scalp. The case is reported by Surgeon F. Bacon, U. S. V. Case. — Private A. J. Cook, Co. B, 92d Ohio Volunteers, by the accidental discharge of a pistol in his own hands, received, on November 2d, 1862, a slight bullet wmund of the integuments of the forehead, over the right superciliary ridge. He was admitted to hospital at Charlestown, Virginia. The wound at first granulated kindly; but, on November 10th, the j)atient having, in spite of the protestations of his nurse, removed the dressings, and gone out of doors on a cold, damp day, tetanic spasms of great severity set in, and the case terminated fatally within tw'enty-four ho^irs. Acting Assistant Sm-geon McEwen reports the case. Case. — Private Wilson Miller, Co. C, 116th United States Colored Troops, aged 26 years, was wounded, in an engage- ment before Petersburg, April 2d, 1865, by a conoidal ball, which lodged two inches above the left ear. He was taken to the hospital of the Second Division, Twenty-fifth Corps, where the ball was removed. On April 5th, 1865, he was admitted to the hospital at Fort Monroe. He was placed in a hosj)ital tent, and unavoidably exposed to dampness owing to inclement weather. On April 14th, trismus commenced, and spasms gradually extended to the muscles of the chest, abdomen, and extremities. Active purgatives were given, until the bowels w'cre thoroughly evacuated, after which opium was prescribed without effect. Subsequently, ether and chloroform were administered, with but temporary benefit; assafoetida also, was ineffectually administered per anum in large and repeated doses. Death occurred on April 20th, 1865. Assistant Surgeon E. McClellan, U. S. A., reports the case. Case. — Lieutenant Patrick Morris, Co. M, 62d Pennsylvania Volunteers, aged 30 years, received, at the battle of Gettysburg, Pennsylvania, July 2d, 1863, a gunshot scalp wound of the occipital region. On July 3d, he was admitted to the hospital of the Fifth Corps. On July 7th, tetanus, in the form of trismus, made its appearance. Chloroform was administered by inhalation, and free incisions were made through the scalp near the seat of injury. These measures appeared, for a time, greatly to alleviate the symptoms, but after a temporary remission, these recurred with increased severity, and death took place, on July 11th, 1863. Case. — Private Thomas J. Severance, Co. F, 2d New Hampshire Volunteers, aged 25 years, was wounded, at the battle of Gettysburg, Pennsylvania, J uly 2d, 1833, by a fragment of shell, which caused a wound of the right side of the scalp, j)Osterior aspect. He was, at first, admitted to the Seminary Hospital, and, on July 8th, was transferred to Turneris Lane Hospital, Pluladelphia. The general health of the patient was good. The edges of the wound were inflamed, and cold water dressings were therefore applied, and continued until July 16th, when the patient complained of stiffness of the jaws. The throat was rubbed with strong ammoniacal liniment. On the following day, there was confirmed trismus, and, in addition to this, emprosthotonos occurred during the night. Warm cataplasms were a])[)lied to the wound, and anodynes were administered internally. On July 18th, the anodynes were continued, and as the wound was found to bo suppurating freely, a supporting course, consisting of milk punch, and injections of beef tea, was resorted to. On July 19th, tlie patient appeared to be much the same, manifesting a great indisposition to be disturbed. The treatment of the preceding day was continued, together with the apj)lication of powerful rubefacients along the spine. Death resulted on the morning of the 20th of July. The api)arent cause of the inva-sion was damp weather, as it occurred during a very damj), rainy period. The case is recorded by Assistant .Surgeon C. H. Ahlen, U. B. A. The following case was regarded as an insttince of recovery from traumatic tetanus, hut the evidence is anything hut satisfactory : 84 WOUNDS AND INJURIES OF THE HEAD Case. — Private Conrad Wentzell, Co. E, 75tli Penneylvauia Volunteers, aged 34 j-ears, received, at the battle of Gettys- burg, July 1st, 18C3, gunshot wounds of the left side of the head and of the upper third of the left arm. He was at once admitted into Seminary Hospital, Gettysburg, and thence, on July 13th, sent to Satterlee Hospital, Philadelphia. There were indications of trismus or tetanus; but upon chloroform being inhaled, no spasms or pain recurred. On the ICth, the jiatient complained of burning pain in the wound, but on the 25th, he was doing well. The wound looked healthy, and no further complication ensued. He was furloughed on September 28th, 1863, and transferred to Veteran Reserve Corps on Febniary 29th, 1864. Pyoemia . — The reports specify five cases of gunshot wounds of the scalp in which pytemia supervened : Case. — Private T. D. Biggs, Co. I, Anthorn’s Regiment, was, on July 5th, 1863, admitted to the hospital steamer R. C. W^ood, with a gunshot wound on the left side of the scalp. On July 7th, he was transfened to the Overton Hospital, Memphis, Tennessee, and, on July 31st, he was sent to the Church Hospital of the same city, where he died, on September 3d, 1863, of septica?mia, accompanied by embolic obstructions in some of the smaller arteries. Case. — Private George Gold, Co. I, 155th Pennsylvania Volunteers, aged £3 years, was admitted to Harewood Hospital on October 7th, 1864. He had been wounded at Poplar Grove Church, on September 30th, by a musket ball, which struck the scalp, passing from before backwards, tearing up a portion about three inches in length by one inch in breadth, laying bare the skull and denuding it of its pericranium for the space of three inches in length and one inch in breadth, through the middle of which space the sagittal suture passed, meeting the coronal at the anterior border. The patient was carefully watched for symp- toms indicative of cerebral or meningeal inflammation ; but none were manifested up to the moment of his death, unless a slight drowsiness, which, at tho time, was attributed to the administration of eight grains of Dover’s powder, might be so regarded. Ho was u]) and about the ward, complaining of nothing except the wound in the scalp, and receiving no treatment, except simple dressings, until the morning of October 18th, when he spoke of a slight pain in the left side of the chest, over the lower lobe of the lung. There was some dullness on percussion over the part complained of, but no marked physical signs of inflam- matory mischief. On October 19th, the patient was worse. The pain in the left chest was mot:e severe, resembling that of pleurisy; the pulse was full and frequent; the tongue brown and rather dry ; there was very little cough, and no expectoration. On percussion, the right side was very dull over the lower lobe, less so over the upper lobe. The respiratory murmurs were nearly if not quite normal, over the whole of the right lung. Examination by auscultation unsatisfactory, on account of the turbulent action of the heart and the catching character of the respiration. There was no cephalic or nervous symptoms. On October 20th, the patient appeai'cd more comfortable in the early part of the day, the respiration less labored, and pulse more quiet, and tongue more moist; towards the latter part of the day, howevei’, the symptoms increased in severity. Great dullness over whole of left side of chest W'as noticed, and greatly diminished resonance on the right side. The vesicular murmur was heard over a small portion of the superior lobe of the left lung only. Moist friction sounds over nearly the whole of the left lung could be heard, together with bronchial respiration, and, at some circumscribed parts, a very coarse crepitation. On the right side the vesicular murmur was rather faint, and greatly obscured by bronchial respiration. On October 21st, there was less pain and dyspnoea, very little cough, with a soft infrequent pulse, pale countenance, and increasing dullness on percussion over the right side. Towards the latter part of the day there was less drowsiness. The patient died at half-past eight o’clock, on October 22d, 1864. He was perfectly sensible and rational within ten minutes of his death. A post mortem examination was made three hours afterwards. Cadaveric rigidity was strongly marked; the skin of the chest and face was of a deeply jaundiced hue. On making an opening into the chest, about twenty ounces of yellow serum was found in the left pleura, none in the right. The pleural cavities of both sides, but jiaiticularly the left, were covered to a considerable extent with coagulablo lymph of considerable firmness. The left costal and pulmonary pleurte were bound strongly together by broad, thick bands, the r('sult of some foiiner disease. There were also a few much less firm attachments on the right side. The lower lobe of the left lung was in a state of gray hepatization, the upper lobe in that of red hepatization, and in both, at various points, were found circum- scribed deposits of pus, containing from one-half a drachm to a drachm each. The lower lobe of the right lung was in a state of red hepatization, and the middle and upper lobes were greatly congested. In the lower lobe were found two or three purulent deposits, which appeared to form centres of inflammation, or metastatic foci. The wound along the scalp appeai-ed as during life. Pus was found along the coronal and sagittal sutures, throughout the whole extent, dissecting the scalp from the bone, to the breadth of one inch. The skull was roughened, and deprived of })ericranium to that extent. The portion of the wound which had been originally denuded had begun to exfoliate, a line of separation being visible around it. On removing the calvaria, a thin layer of pus wms found between the hone and dura mater, extending along the sagittal and coronal sutures to the same e.xtent as on the external surface, the amount of pus within the skull being less than one drachm. There w'as a narrow strip of the dura mater each side of these sutures which was inflamed; at other j)arts this membrane was healthy. The arachnoid and pia mater were perfectly normal. The brain and its ventricles, the cerebellum, medulla oblongata, and roots of all the cerebral nerves were carefully examined, and no lesions were discovered. The heart and its valves, the vena cava and azygos, the pulmonary veins and arteries, the jugulars, and the blood-vessels of the brain, were in a normal condition. The liver was apparently healthy. Acting Assistant Surgeon Cobb recorded the case. Case. — Private Rufus Hedges, Co. G, 10th Michigan Volunteers, received, in the engagement at Peach Tree Creek, Georgia, July 21st, 1864, a slight gunshot wound of the scalp. He was admitted into the field hospital of the Second Division, Fourteenth Army Corps, on the same day. On the following day, he was conveyed to Hospital No. 2, at Chattanooga, Tennessee. On August 7th, he was transferred to the Sherman Hospital, at Nashville. A supporting diet was given, and simple dressings used. The patient died, on August 30th, 1864, of pyaemia. Surgeon William Threlkeld, U. S. V., reports the case. COMPLICATED GUNSHOT WOLNDS OF THE SCALP. 85 Case. — Private Gilmer P. Rook, Co. B, 9tli Maine Volunteers, aged 18 years, received, at the siege of Petersburg, Vir- ginia, July 8th, 1834, a gunshot wound of the scalji. He was admitted to the hospital of the Second Division, Tenth Corps, and was thence sent to the McDougall Hospital, at Fort Schuyler, which he entered on July 27th. He died, on July 31st, of double pneumonia and icterus, and other signs of pyaemia. Case. — Private A. Russell, Co. K, 53d North Carolina Regiment, received, at the battle of Gettysburg, Pennsylvania, July 3d, 1833, a gunshot wound of the scalp. He was admitted to the Seminary Hospital, and, on July 17th, was transferred to the De Camp Hospital at David’s Island, New York. Pyaemia supervened, and death occurred on September 20th, 1863. Surgeon Charles Gr.ay, 11th New York Cavalry, reports the case. Complications from Intercurrent Diseases. — In twelve cases of gunshot wounds of the scalp, the fatal results are ascribed to typhoid fever. This term was often employed in a very loose sense by some of the medical officers, being applied not infrequently to a state of exhaustion resulting from irritative or traumatic fever ; Case. — Private George W. Beisel, Co. K, 55th Pennsylvania Volunteers, aged 29 years, was wounded, while on picket, ]\lay 20th, 1834, by a musket ball, which tore the scalp on the left side. He was admitted, on May 23d, to the hospital at Point Lookout, Maryland, furloughed June 24th, and readmitted on August 17th, 1864. Typhoid fever then set in, and death occurred on October 27th, 1834. Case. — Private Chai’les W. Hapenstall, Co. G, 36th Illinois Volunteers, aged 18 years, was wounded, at the battle of Franklin, Tenns Shields, Co. I, 69th New Yoilc Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot wound of the scalp. He was admitted to the hospital of the Third Division, Ninth Corps, on Decemher 14th, was sent to the Armory Square Hospital, Washington, D. C., and, on December 19th, transferred to the De Camj) Hospital, New York Harbor, where he died, on January 9th, 1853, of pneumonia. Surgeon J. Simons, U. S. A., recorded the case. Case. — Private George 51. Snow, Co. D, 25th Wisconsin Volunteers, aged 23 years, received, at the battle of Eesaca, Georgia, 51ay 14th, 1864, a shell wound of the scalp. He was, at once, admitted to the hospital of the Sixteenth Corps. On 51ay 19th, he was sent to the field hospital at Chattanooga, on 5Iay 21st, was transferred to Hospital No. 1, Nashville, and thence, on May 24th, was sent to the Brown Hospital, Louisville, Kentucky. He died, on June 9th, 1864, of pleuro-pneumonia. Case. — Private William Spencer, Co. F, 51st Ohio Volunteers, received, at the battle of Kenesaw 5Iountain, June 22d, 1864, a shell wound of the scalp. He was conveyed to Nashville, Tennessee, and admitted to the Cumberland Hospital, on June 26th. Typhoid pneumonia supervened, and the patient died, on July 3d, 1864. Three fatal cases of gunshot scalp wounds were complicated by the supervention of variola : Case. — Corporal Edgar Calkins, Co. D, 5th 5Iichigan Voluntefh's, 'received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot wound of the right side of the scalp. He was admitted to the hospital of the First Division, Third Corps, and, on December 19th, was sent to 5Iansion House Hospital, Alexandria, and, on April 10th, 1863, symjitoms of small-pox being manifested, he was transferred to hospital for eruptive diseases, at Kalorama, Washing-ton, D. C., where he died, on 5Iay 27th, 1863, of varioloid with cerebral symptoms. Case. — Private John Crandall, Co. K, 04lh New York Volunteers, aged 33 years, received, at the engagement at North Anna, Virginia, 5Iay 18th, 1864, a scalp wound of the occipital region, from a musket ball. He was sent to Washington, and entered Carver Hospital on the 24th, and, on the 27th, was transferred to the Summit House Hospital, Philadelphia. Here he had variola. When partially convalescent he was removed, July 14th, to Turner’s Lane Hospital; again, on October 10th, to Filbert Street Hospital, and again, on Fobruaiy 16th, 1865, to Islington Lane Hospital. Here he died, on February 24th, from the effects of the wound, and of the sequela? of small pox. Case. — Sergeant Charles Harbstrutt, Co. D, 74th Pennsylvania Volunteers, received, at the battle of Gettysburg, .July 2d, 1863, a shell wound of the integuments on the back of the head. Ho was admitted, on the same day, to the Seminary Hospital, at Gettysburg, to be transferred on the 18th, to the hospital at York, Pennsylvania. On October 8th, variola super- vened, and the patient died, November 6th, 1863, from the conjoined effects of tlie wound and fever. » In one case of gunshot scalp wound hepatitis is adduced as the cause of death ; Case. — Private Edward 5IcDole, Co. G, 7th New York Heavy Ar tillery, received, irr an engagement before Petersburg, Virginia, June 16th, 1864, a scalp wound, caused by a fragment of shell. He was admitted to the hosjiital of the First Division, Second Army Corps; on June 21st, he was sent to the Lincoln Ho.sjiital, Washingtorr, D. C., and, on Jurre 28th, to the Satteriee Hospital, I’hiladeljihia, where he died, on July 9th, 1864, “of hejratitis.” Diarrhoea is reported as a fatal complication in four cases : Case. — Private Joseph Coad, Co. F, 3d Mairre Volunteers, aged 35 years, was wourrded, at the b.attle of the Wildcraress, Virginia,- 5Iay 8th, 1864, by a conoiilal ball, which lacerated the right side of the scaljr. He was sent to Washington, and admitted, orr May 27th, to Cai-ver Hospital, where simple dressings were ajiplied to the wound. De.'ith occurred oir June 18th, 1864, from “chrorric diarrhoea.” Surgeon O. A. Judsorr, U. S. V., recorded the case. 88 WOUNDS AND INJUEIES OF THE HEAD, Case. — Private A. F. Dana, Co. E, United States jMarine Coi’ps, aged 22 years, was wounded, at the assault on Fort Fisher, January 15th, 1865, by a fragment of shell, which lacerated the right side of the scalp and caused a transitory concussion of the brain. He was made a prisoner, but was shortly afterwards exchanged, and, on February 3d, 186.5, admitted to the hospital at Point Lookout, Maryland. Here he died, on July 18th, 1865, of “chronic diarrhoea.” Surgeon G. L. Sutton, U. S. V., records the case. Case. — Private Alvah B. Small, Co. C, 20th Maine Volunteers, received, at Gettysburg, Pennsylvania, July 3d, 1863, a gunshot wound of the scalp. He was, at once, admitted to a field hospital, and, on July 8th, was transferred to the Satterlee Hospital, at Philadelphia. Sunple dressings were applied to the wound, and tonics and astringents were administered internally. Chronic diarrhoea, fi’om which he was suffering, persisted, and death ensued August 28th, 1863. Case. — Corporal Richard H. Van Devine, Co. K, 1st New Jersey Infantry, aged 28 years, received, at the battle of Spottsylvania, Virginia, May 12th, '1864, a gunshot wound of the scalp. He was admitted, on June 11th, to the Mount Pleasant Hospital, Washington, D. C., and, on June 20th, transferred to the Summit House Hospital, Philadelphia. At the period of his admission he was very much reduced, and he died, on July 10th, 1864, “of diarrhoea.” Surgeon J. H. Taylor, U. S. V., records the case. Privation in prison is assigned as the cause of death in one case : Case. — Private John A. Brown, Co. B, 73d Blinois Volunteers, was wounded, at the battle of Chickamauga, September 19th, 1863, by a musket ball, which produced a lacerated wound of the scalp. He was made a prisoner, and was sent to Andersonville, Georgia, where he died, on August 17th, 1864. The following case terminated fatally in consequence of the supervention of diph- theritis : Case. — Private Julius McKnight, Co. D, 27th U. S. Colored Troops, aged 23 years, received, on July 30th, 1864, at the siege of Petershurg, yirginia, a gunshot wound of the scalp. He was sent to the hosjiital for Colored Troops, a few miles in the rear, at City Point. Here little importance was attached to the wound of the head, and the patient was entered on the register as suffering fi-om remittent fever. On August 14th, he was sent to Philadelphia, to the Summit House Hospital, where the scalp wound was regarded as serious. As it was progi’cssing favorably, light, simple dressings were apjilied. In Septem- ber, symptoms of diphtheria were manifested, and the disease making very rapid progress, the patient died, on Se])tember 2ffth, 1864. At the autopsy, the mucous coat of the fauces and trachea appeared to be ulcerated and disorganized. A tough tuhular membrane lined the larynx, trachea, and bronchi, even to the smaller ramifications; and in the larger air passages, this pseudo-membrane was detached. It was of a yellowish gray or ash colored hue. The lungs were much engorged. An abscess containing half an ounce of pus was found in the right lung. Entangled among the columnaj earner of the right ventricle of the heart was a concretion, half an ounce in weight, very similar in appearance to the membranous exudation in the lung. It was very unlike the ordinary fibrinous coagula or heart clots so frequently observed in autopsies, and, under the microscojie, presented the same histological elements as the exudations in the air passages. Surgeon J. H. Taylor, U. S. V., records the case. In another of the one hundred and sixty-two fatal gunshot scalp wounds, the fatal result was probably due to delirium tremens : Case. — Corporal William Quinn, Co. A, 95th New York Volunteers, aged 29 years, received, at the battle of Gettysburg, July 2d, 1863, a gunshot scalp wound of the frontal region. After a few days treatment in field hosj)ital, he was sent to Phila- delphia, and admitted into Satterlee Hospitid on July 11th. He died “from mania a potu” on August 23d, 1863. At the autopsy, an extensive discoloration of the forehead and face was observed; but no fracture of the cranium or injury of the brain could be detected after the most careful exploration. There was cirrhosis of the liver; but the other viscera showed no organic alteration. Surgeon I. I. Hayes, U. S. V., records the case. The five following cases are reported as slight gunshot wounds of the head. From the evidence derived from prescription books, hospital registers, monthly reports, and other sources, it is inferred that the injuries were diagnosticated as gunshot wounds of the scalp only, and that no lesions of the bony walls of the skull were discovered after death : Case. — Corporal Isaac Foster, Co. H, 98th New Y'ork Volunteers, aged 23 years, received, at the battle of Cold Harbor, Virginia, June 3d, 1864, a gunshot wound of the head. He was admitted to the hospital of the First Division, Eighteenth Corps, and was thence transferred to hospital Division No. 2, Alexandria, Virginia, where he died, on June 21st, 1864, from wound. Surgeon E. Bentley, U. S. V., records the case. Case. — Corporal Henry French, Co. I, 173d New York Volunteers, received, on May 12th, 1863, a gunshot wound of the head. He was admitted to the Alexander Hospital, Brashear City, Louisiana, where he died, on Slay 25th, 1863. Surge on C. Powers, 160th N. Y. Vols., reports the case. Case. — Private W. B. Griffith, Co. H, 20th Virginia Regiment, was brought to the Chimborazo Hospital, Richmond, Virginia, on December 10th, 1864, with a gunshot wound of the head. 1 le died on December 25tb, 1864. Assistant Surge on J. B. Wily, C. S. A., records the case. GUNSHOT WOUNDS OF THE SCALP. 89 Case. — Private Charles Bussell, Co. B, 37th Massachusetts Volunteers, was wounded at the battle of Winchester, Septem- ber 19th, 1864, and is reported by Assistant Surgeon Elisha M. White, 37th Massachusetts Volunteers, as “killed in battle.” He was not killed, however, but was conveyed to the general field hospital of the Sixth Coi’ps, whence the case is reported by Sur- geon S. A. Holman, U. S. V., as a flesh wound of the scalp, produced by a fi-agment of shell. On October 4th, the patient was transferred to Sheridan Hospital, where the diagnosis is recorded by Surgeon F. V. Hayden, U. S. V., as a gunshot wound of the scalp, involving the integument only, and by Surgeon W. A. Barry, 98th Pennsylvania Volunteers, as a gunshot wound of the head with injury of the skull. The patient died on October 7th, 1864. Case. — Private Edward Wilmore, Co. K, 1st Missouri Volunteers, received, at the battle of Wilson’s Creek, Missouri, August 10th, 1861, a gunshot wound of the head and the face. He was, on the same day, admitted to the hospital at Springfield, where he died, on August 25th, 1861. As contused or lacerated wounds of the scalp are rarely fatal, unless followed by secondary disease of the cranium or its contents, or by hsemorrhage, sloughing, pyaemia, or tetanus, numerical estimates of the results of gunshot injuries of the integuments of the head can teach us little more than the relative frequency and fatality of such complications. The foregoing brief abstracts of two hundred cases include thirty-eight recoveries and one hundred and sixty-two fatal cases. The tabular statement, on page 70, of 7,739 cases of gunshot scalp wounds gives a near approximation to the truth regarding the results of such injuries, every allowance being made for errors in diagnosis and imperfection in the returns.”' The histories of 3,420 cases have been traced from hospital to hospital until the complete recovery of the patients' and their return to duty was ascertained. In like manner, the histories of 132 Confederates who recovered and were exchanged, released, or paroled, and of 127 United States enlisted men who were sent to modified duty, have been followed to their termination. The terminations of 1,186 cases in resignation, discharge, dismissal, failure to return from leave or furlough, or in desertion, have been ascertained. 1,609 patients have been followed through successive transfers to hospitals or convalescent camps ; though the records do not furnish evidence of the ultimate disposition made of them, it may be inferred that they recovered, since their names do not appear upon the alphabetical registers of deaths. Finally, 1,103 cases are derived from the field casualty lists, and, although they are entered as cases in which the terminations are “unknown,” it may be inferred, as the names do not reappear on any of the hospital registers, that the injuries in these cases were slight, and that the patients were returned to duty almost immediately. Grouping those sent to active or modified duty, those transferred, paroled, or exchanged, and those who did not enter permanent hospitals, in one class, and in another those who were discharged, or dismissed, or reported as deserters, the 7,739 cases are accounted for as follows : 162 patients died, 1,186 were discharged, and 6,391 recovered. But, as 1,186 patients discharged include many who were mustered out on the expiration of their term of service, or who failed to return from furlough, or who deserted, a nearer approximation to exact truth is attained by the statement that 162 died, 522 were discharged on certificates of physical disability, and 7,055 probably recovered. The death-rate of gunshot wounds of the integuments of the cranium during the late war was, therefore, about 2.09, or nearly one fatal case in 48. * I am anxious to point out how far each numerical estimate may be relied' upon, and to indicate the sources of error. The reports of each of the seventy-seven hundred and thirty-nine cases of gunshot wounds of the scalp recorded in Table III, were separately examined and were entered upon the register of gun.shot wounds of the scalp, when the evidence indicated the proba- bility that the injury was hmited to the integument. Jhe tabular statement is a correct transcript from the official records, and an index of the average results of the injuries to which it relates. To suppose that no cases of contusion of the skull or injury to the brain were included in the statement, would imply a precision in diagnosis and perfection in returns that are unattainable. In a final revision of the reports, I have set aside twenty-one cases, including eleven that were fatal, recorded among the scalp wounds as probably examples of contusion of bone, and have transposed about an equal number from the register of contusions and partial fractures of the skull. 12 90 WOUNDS AND INJURIES OF THE HEAD, The Surgical History of the British Army in the Crimea, compiled by Staff Surgeon T. P. Mattliew,''’ contains a record of 668 gunshot wounds of the head designated “ simple flesh contusions and wounds;” 8 of these patients died, 73 were invalided, and 587 were returned to duty, a mortality -rate of 1.02, or one in 83. The surgical report of the French army in the Crimea, by M. Chenu,^ presents a tabular statement of 1,633 gunshot wounds of the head distinguished from fractures of the cranium and wounds of an undetermined O nature, and designated “ plaies simples. et contusions.” Of these patients, 157 died, 17 were pensioned, and 1,459 returned to duty ; a death-rate of nearly ten per cent. In the Eeport on the Italian AVar of 1859, the same author J enumerates 308 cases of gunshot wounds of the head as “ contusions et plaies contuses.” Of these patients 19 died, 4 were invalided, and 285 returned to duty, or about one death in 16. These discrepancies are quite explicable. M. Chenu’s returns are very incomplete, the slight cases being omitted. The British returns include contusions by spent balls and trivial injuries ; but exclude fatal results from intercurrent diseases. The American returns comprise a large series of both slight and severe cases, and include the fatal results due to diseases contracted in hospitals. The danger of injuries of the skull varies greatly, according to the part involved ; but in wounds limited to the integument little difference is observed, save that those of the temporal and occipital regions are more liable to hsemorrhage. In 5,246 cases of gunshot wounds of the scalp, the precise location of the wound is not specified. In the remaining 2,493 cases the seat of injury is reported as follows ; Table IV. Seat of Injury in Two Thousand Four Hundred and Ninety-three Cases of Gunshot Wounds of the Scalp. The gunshot wounds of the scalp presented many varieties. There were mere scratches of the skin made by the sharp angles of shell fragments, solutions of continuity resembling incised wounds, superficial injuries analogous to ordinary contusions with abrasion of the cuticle furrows or cleanly cut grooves made by balls moving with great velocity, lacerations with flaps or with much loss of tissue, long fistulous tracks or tunnel- like passages styled by French surgeons plaies en seton, and wounds with lodgment of the missile. * Medical and Surgical History of the British Army which served in Turkey and the Crimea during the War against Russia, in the years 18 .j 4-’55-’5G, London, 1858, Vol. II, p. 28G. + Eapport au Conscil de Sante dfs Armees sur les llcsuUats du Service Medico-Chirurgkal pendant la Campapne d’ Orient en 1854-’r).5-’.5G. Par J. C. CnENU, Paris, 1855, p. 1.34. t Statistique Mcdico-CJururqicale de la Campapnc d’ltalie en 18.59 et 1800. Par J. C. CiucNU, Paris, 1809, Tome II, ]). 424. GUNSHOT WOUNDS OF THE SCALP. 91 The abrasions and superficial cuts require no other comment than the Hippocratic aphorism, that no injury of the head is too slight to he despised ; the furrowed wounds, because of the rounded form of the head, are usually very limited in length ; the extended lacerations are commonly produced by shell fragments or by elongated musket balls striking sideways ; long fistulous tracks are made by both round and yylindro-conical small-arm projectiles deflected by the dense tissues of the scalp, but the longest occur when a round ball strikes obliquely and runs around the head, such cases being rare unless attended by contusions of bone ; the wounds resembling incisions are not exempt from slight loss of tissue and consequent inevitable suppuration. The wounds with lodgment of missiles will be noticed presently, after adverting to the relative frequency of wounds from the different varieties of gunshot projectiles. In the returns of 4,002 cases, the nature of the gunshot projectile inflicting the injury is specified in the reports, and in 3,737 cases this particular is not referred to, or was undetermined : Table V. Nature of Missile in Four Thousand and Two Cases of Gunshot Wounds of the Scalp. NAME OF MISSILE. No. OF Wounds. Conoidal Musket Ball 2,G12 384 Explosive Musket Ball - 2 Buck Shot 94 Pistol Ball - 25 Solid Canon Ball 3 Shell Fragments 861 Grape Shot 9 Case and Canister Shot and Shrapnel 6 Torpedo Fragments - 4 Piece of Iron 2 Total, 4,002 This statement indicates that 72.6 per cent., or nearly three-fourths of the gunshot wounds of the scalp, were caused by small-arm missiles, and that, without any attendant injury to the skull or concussion of the brain, the scalp may be wouuded by the largest projectiles from artillery. The form, size, and velocity of missiles have very important relations to the nature and extent of fractures, wounds of the great cavities, and some classes of flesh wounds ; but the soft parts covering the skull are so thin, that distinctions referable to the nature of the projectil^ causing flesh wounds of this region are not well marked, and suggest few considerations of interest. The varieties in gunshot scalp wounds depend more upon the velocity than the dimensions or shape of the missile. Cleanly cut furrows were made both by musket balls and fragments of shell in rapid flight, and very ragged wounds were inflicted not only by shell fragments, but by nearly spent or glancing musket balls. 92 WOUNDS AND INJUEIES OF THE HEAD In sixty-five cases, or less than one per cent, of the gunshot wounds of the scalp, foreign bodies lodged, and were extracted from beneath the integument.x They were chiefly small-arm projectiles, either nearly spent or diminished in velocity by deflection that made no exit wounds ; but small fragments of shells, iron balls from spherical case, and buttons and bits of metal, torn from the soldier’s uniform or equipment, were occasionally extracted. A few illustrative cases will not be uninteresting : Case. — Private Diedridi Dasenbuck, Co. C, 151st Pennsylvania Volunteers, was wounded, at the battle of Gettysburg, July 1st, 18G3, by a battered conoidal musket ball, which struck the scalp an inch and a half behind the right ear, and, passing forward beneath the integument, lodged in the right cheek. He I'cceived another wound, the entrance being on the right side of the neck, at the border of the trapezius, two inches within and above the acromio-clavicular articulation, the missile passing subcutane- ously and lodging above the middle of the right clavicle, whence it was removed through a button-hole incision, on July Sd. He was treated for a few days in the Seminary field hospital, at Gettysburg, Penn- sylvania, and was then sent to Philadelphia, and admitted, on July 11th, to the hospital in Turner’s Lane. On July 17th, the position of the larger foreign body was ascertained, and it was removed from the cheek, by an incision through the inner or huccal surface, fi-om its lodgment immediately below the orifice of the duct of Steno. Both wmunds cicatrized promptly, and the patient was returned to duty perfectly well, on August 17th, 1863. The ball removed from the cheek was very much battered, and included in its folds a tuft of hair. The other missile extracted was a flattened piece of lead, not improbably a fragment of the projectile just described. This, a cylindro-conical ball of English manufacture, had apparently struck and split upon some hai’d surface before inflicting the wound in the scalp. The two projectiles were con- ti-ibuted to the Army Medical Museum by Acting Assistant Surgeon Charles Carter, and are represented in the adjacent wood-cut, (Fig. 27). The notes of the case were furnished by Assistant Surgeon C. H. Alden, U. S. A. A ball lodged under the scalp is, usually, very readily detected ; but, in rare instances of lodgment in the temporal fossa or occipital region, there may be some obscurity. The next abstract suggests the utility, in such cases, of the probe invented by M. bT^laton ; Fig. 27. — Projec- tiles extracted from a patient with a wound of the scalp. — Spex. 4520 and Spec. 4527, Sect. I, A. M. M. Case. — A soldier of the First Brigade, First Division, Fifth Corps, was wounded, on May 20th, 1854, in the advance from Spottsylvania towards the North Anna river, by a musket hall, which entered the left cheek over the canine fossa of the left superior maxillary, and passed outward and- backward eight inches, without apparent injury to the bone, and lodged under the scalp above the nucha. The discoloration of the porcelain tip of a N61aton probe passed through the long fistulous Fig. 28.— Elongated track, revealed the exact location of the ball, which was immediately extracted, on the field, by Surgeon neafh’^tjie'^^ocoipTtTl 14Cth New York Volunteers. The notes of the case, together with the specimen, repre- gion of the scalp.— ^pec. sented in the wood-cut (Fig. 28), were forwarded by Assistant Surgeon J. Sim Smith, U. S. Anny. In 3153, Sect. I, A. Jt. M. letter from Dr. Flandrau, dated Borne, New York, February, 1870, he refers to this case, and mentions that, “in a careful examination of the wound, several surgeons were unable to decide whether bone or ball was touched, until the porcelain-tipped probe promptly settled the question.” Very rarely a fragment of shell may lodge under the scalp without injuring the bone, as in the following instance : Case. — Private G , Co. F, 41st New York Volunteers, in the assault on the works on John’s Island, South Carolina, February 11th, 1864, was wounded in the right temple. He walked from the battle-field to the field hospital, several hundred yards in the rear, and presented himself to Surgeon Samuel Brillantowski, of his regiment. A crucial wound was found in the temporal region, three-fourths of an inch from the external angle of the right orbit. An irrcgulaily triangular frag- ment of a shell was found beneath the integument, and was speedily extracted. Under approjiriate treatment the wound healed perfectly in six weeks, the patient recovering without any impairment of vision. The specunen, contributed by Surgeon Brillantowski to the Museum, with the foregoing notes, is represented in the adjacent wood-cut. (Fig. 29.) Fig. 29. — .Small cast-iron fragment, apparently from tlio base of a cylindrical shell. — Spec. 234.5, Sect.. I, A. M. M. Brevet Lieutenant Colonel 0. H. Laub, Surgeon U. S. Army, lately informed the writer that, during the hostilities with the Seminoles in Florida, the lodgment of small rifle balls under the scalp was not an infrequent occurrence. Surgeon Laub cited three instances of removal of such missiles from beneath the frontal integument, in the cases of soldiers wounded near Fort Miller. The short incisions necessary for the removal of the Vialls healed within two weeks, and there were no unpleasant consequences. GUNSHOT WOUNDS OF THE SCALP. 93 Gunshot contusions of the head witliout breach of surface, of sufficient severity to cause ecchymosis, were invariably attended by . commotion, concussion, or intracranial extravasation, and are classified, and will he described, in connection with injuries of the encephalon. Among the cases reported as gunshot wounds of the scalp, were many followed by vertigo, headache, persistent pain at the point struck, impairment of the special senses — amaurosis and deafness being especially frequent — by mental imbecility, by epilepsy, and various forms of paralysis ; but, as in all of these cases the ulterior effects indicated that there must have been some injury to the cranium or its contents, they were nearly all excluded from the return on page 70, and will be considered in the next subsection. It has not been practicable to ascertain the nature of the disabilities for which one hundred and twenty-seven enlist^xl men were transferred to the Veteran Reserve Corps, after receiving gunshot wounds of tlie scalp. The reports to this Office afford no information on the subject. The surgeons’ certificates, under which the men were transferred, were forwarded to the Provost Marshal General, and duplicates were sent to the Adjutant General; but these certificates only state the seat of injury, without detailing its consequences, and the degree of disability, without specifying its nature. A critical examination of the returns constrains me to disagree with Reudorfer,^ Denonvilliers," and other modern authorities, in regard to the comparative infrequency of gunshot wounds limited to the integuments of the cranium. In gunshot wounds of the head, the fractures and penetrating and perforating wounds of the brain undoubtedly exceed in number the lesions of the exterior soft parts ; but so many of the wounded of the first class are left dead on the field, that it may be safely asserted that of the cases brought under surgical treatment, the scalp wounds are more numerous than the fractures. The return, on page 70, of 7,739 cases of gunshot wounds of the scalp, unquestion- ably includes some instances complicated by injury to the skull or its contents ; as, for example, the case of Corporal Carpenter, of which an abstract is given on page 83. But such examples are few, so that in a final revision of the registers of gunshot injuries of the head, made since the preceding pages were printed, I have found but twenty-one cases in which the evidence furnished by the reports indicated the probability of any lesion of the cranium or brain. There is great difficulty, no doubt, in distinguishing the various classes of gunshot wounds of the head, both in practice, and in the analysis of brief and often imperfect reports. But, from the evidence offered, it would appear incontestable, that in the cases of gunshot injuries of this region which come under the care of the surgeon, the wounds of the soft parts outnumber the fractures. The divisions here established in classifying gunshot wounds of the head, are, of course, in a measure, arbitrary and artificial, and are only justified by the necessities of analysis and of study. For these purposes, it is requisite to separate these lesions, and to present particular descriptions of each ; but the practical surgeon will never lose sight of the fact that, in examining patients, he will constantly encounter complications of disorders of every variety. * Neudorfer. “Iin Kriege kommen derlei Verletzungen dcr Scliadelbedeckungen viol soltcmer vor, als iniiii glauboii sollte, weil die ineiston Scbussverletzungen des Kopfes sicli nur ilussorst solten aiif die Woiclitlieile bescbiaiikon/’ u. s. \v., in Uandhuch der KrieijscMrunjie, Leipzig, 1837. Zweite Ilalftc, I'lrstcs S. 6. ’^Denonvilliers et Gosselin. "Rareinent lea coups de feu boniont leiir action aux parties inolles.” Compendium dc Chirurrjic Pratique, Art. Lesions Traumatiques du Crane, T. 11, p. 570, I’aii.s, 1851. 94 WOUNDS AND INJUEIES OF THE UEAD, In discussing, on page 89, the ratio of fatality of gunshot wounds of the scalp, deaths from intercurrent diseases have been included in the estimates, in conformity with the system of reports in the medical department of the United States Army. In one hundred and twenty-two of the one hundred and sixty-two fatal cases, death would appear, beyond question, to have resulted, either directly or indirectly, from the effects of the wound ; some form of encephalitis being the proximate cause in ninety-eight cases, and such complications as erysipelas, gangrene, hsemorrhage, tetanus, and pyaemia, in twenty-four cases. The remaining forty fatal cases include twenty-nine deaths, attributed to typhoid and malarial fevers, and jmeumonia, in regard to which it is difficult to determine how far the febrile or pulmonary symptoms were symptomatic only, and eleven deaths, due to variola, diphtheritis, hepatitis, privation, and delirium tremens^ the original injury having little, if any connection with the fatal event. The duration of life after the reception of the injury, of the one hundred and sixty-two fatal cases, taking an average from them all, was forty days. The mean interval in the cases in which the fatal terminations were due to encephalitis, was twenty-four days. Some of the patients who succumbed to secondary diseases less directly dependent on the injuries received, survived many months. As other examples of the more common complications of gunshot wounds of the scalp, as hsemorrhage, erysipelas, sloughing, and abscess, will be offered in the next subsection, it will be more convenient to defer the consideration of these subjects. Some observations on cerebral irritation and on traumatic encephalitis will be presented at the close of the chapter. Uemarks upon the cases of tetanus and pyaemia will more appropriately find a place in the chapters specially devoted to the discussion of these important affections. The Army Medical Museum has only a single anatomical preparation^ illustrating gunshot wounds of the scalp ; but possesses a large collection of photographs of patients with such injuries.^ The majority of cases selected for illustration were severe lacerations, or were complicated by erysipelas, or sloughing, or injury to the skull. Four of these photo- graphs are faithfully copied in Plate III, (opp. page 105.) The ordinary primary treatment of gunshot w'ounds limited to the scalp, consisted in washing the parts with a warm sponge, shaving the scalp in the vicinity of the wcnmd, removing foreign bodies, and suppressing liEemorrhage, when necessary, and covering the part with a compress dipped in cold water. Many, perhaps the majority, of the surgeons were accustomed to approximate the edges of the wounds by adliesive strips, and a few even used stitches. It is hardly possible that they anticipated union by first intention ; but they probably hoped to abbreviate the stage of granulation by these methods of dressing. Other surgeons applied, in place of water dressing, a strip of muslin or lint spread with simple cerate, and kept in place by adhesive plaster, and thus avoided the ' Specimen 1302, Section I. — A wet preparation of a portion of the scalp from the right parietal region, perforated by a musket ball which fractured the cranium. The opening made by the ball has been enlarged by two incisions and by the slough- ing of the contused edges. Sergeant J. F , Co. K, 14th Maine Volunteers, aged 34 years, wounded at Port Hudson, Lou- isiana, May 27tli, admitted into hospital at New Orleans, 29th May; died, June 7th, 1833. The specimen was contributed by Assistant Surgeon P. S. Conner, IT. S. Ai-my. See Catalogue of the Surgical Section of the Army Medical Museu n, p. 38. -See Card PnoTOGRAPiiS, A. M. M., Vol. Ill, p. 1, (Case of Sergeant Coletrap;) Vol. Ill, p. 3, (Case of Private Fol- som) — for illustrations of lacerations of the integuments of frontal and parietal regions, without in jury to the skull. See ITioto- GRARIIS Olf SURGICAR C.\SKS, Vol. Ill, ]). 7, (Case of Ferris,) p. 9, (Case of Van Valkenberg,) p. 10, (Case of Shatter,) Vol. VII, p. 1, (Case of Wheeler,) ]>. 3, (Case of Scott,) ji. 4, (Case of Scluller,) p. 5, (Case of Bean,) p. 7, (Case of Kinchelow,) p. 9, (Case of Ilendei'son,) Vol. I, p. 33, (Case of Dougherty)— for a few of the many illustrations of comj)licated gunshot injuries of the scalp. GUNSHOT CONTUSIONS OE THE CEANIAL BONES. 95 necessity of a retentive bandage. It was not customary to lay open the long fistulous wounds where there was an aperture of exit ; hut injections were used to cleanse them from the hairs, bits of clothing, or other foreign bodies that might have lodged in the sinuses. The blind fistulous wounds with a missile at the closed end, were treated by a counter-opening for the extraction of the foreign body, and were thus assimilated to the variety just men- tioned. In some of these “ seton wounds ” the whole track was laid open by sloughing ; in others, suppuration was so abundant that the apertures of entrance and exit aftbrded insufficient space for the elimination of eschars and pus, and it was necessary to make one or more incisions along the track of the sinus. When wounds of the scalp became inflamed, cataplasms of flaxseed meal were commonly applied, or sometimes bread and water poultices, or compresses saturated with warm water. These emollient applications were occasionally medicated by solutions of chlorinated soda, permanganate of potassa, spirits of camphor, and infusions of belladonna. Ointments of the iodide of lead, sulphate of zinc, and nitrate of mercury are among the other local applications reported. In a number of cases where cerebfal symptoms impended, besides resorting to general treatment, ice bladders were applied to the head. This method was adopted with advantage in numerous cases at the Stanton Hospital, at Washington, under the direction of Surgeon John A. Lidell, U. S. V. From the Confederate Hospital No. 12, at Richmond, Virginia, a number of cases of inflamed scalp wounds, successfully treated by continuous irrigation, were reported by Sur- geon W. A. Thom, C. S. A. Gunshot Contusions of the Cranial Bones. — Among cases returned as gunshot wounds of the scalp were many in which exfoliations from the outer table of the skull, persistent pain at the point struck, secondary disorders of the brain, pysemia, and other grave results indicated that there had been contusion of the skull without fracture. The following forty-seven cases of gunshot contusion of the bones of the skull recovered without serious disability, and the men were returned to duty after intervals varying from thirty-five days to forty-three weeks ; Beax, J. W., Lieutenant, Co. I, 5th New Hampshire Volunteers. Gunshot contusion of the temporal hone. Fredericks- burg, Virginia, December 13th, 1862. Returned to duty January 9th, 1863. Bowe, John, Corporal, Co. K, 1st Maryland Volunteers. Denudation of fi’ontal hone by a conoidal musket ball. Peters- burg, Virginia, August 20th, 1864. Returned to duty December 1st, 1864. Cheesboro, Her.Max, Private, Co. G, 46th Pennsylvania Volunteers, aged 23 years. Gunshot contusion of the right parietal bone. Marietta, Georgia, June 15th, 1864. Returned to duty October 2d, 1864. Clark, John, Private, Co. B, 116th Pennsylvania Volunteers. Gunshot contusion of the frontal bone. Fredericksburg, Virginia, December 13th, 1862. Returned to duty June 18th, 1863. CociiR.\.NE, John, Private, Co. H, 141st New York Volunteers, aged 19 years. Gunshot contusion of the bones of the cranium. Resaca, Georgia, May 15th, 1864. Returned to duty August 19th, 1864. Collins, T. J., Sergeant, Co. A, 22d Kentucky Volunteers. Gunshot contusion of right parietal bone. June 4th, 1863. Returned to duty July 22d, 1863. Crouch, James N., Sergeant, 131st Pennsylvania Volunteers. Gunshot contusion of the left side of the occipital bone. Fredericksburg, Virginia, December 13th, 1862. Returned to duty May 12th, 1863. CORMAN, Elisha, Private, Co. A, 5th United States Colored Troops, aged 34 years. Denudation and contusion of the cranial bones at the vertex by a fragment of shell. Deep Bottom, Virginia, September 29th, 1864. Returned to duty December 10th. 1834. Crosby, .1. W., Major, 61st Pennsylvania Volunteers. Contusion and denudation of the right parietal bone by a conoidal musket ball. Wilderness, May 5th, 1864. Returned to duly July 6th,. 1834. Dablaux, Charles, Private, Co. D, 42d Illinois Volunteers. Gunshot contusion of the temporal bone. Chickamauga, Georgia, September 19th, 1833. Returned to duty January 1st, 1864. 96 WOUNDS AND INJUEIES OF THE HEAD Diesze, August, Private, Co. H, 47th Pennsylvania Volunteers, aged 25 years. Contusion and denudation of the cranial bones by a conoidal musket ball. Cedar Creek, Virginia, October 19th, 1864. Eeturned to duty January 19tb, 1865. Dollmeyer, Henry, Private, 3d Independent Ohio Cavalry, aged 26 years. Gunshot contusion of the cranium by a conoidal musket ball. Point Pleasant, Virginia, March 30th, 1863. Eeturned to duty July 5th, 1864. lie recovered rapidly from tlie wound, but remained in hospital on account of distressing attacks of asthma. Dul-e, Hiram, Private, Co. D, 14th Alabama Eegiment. Gunshot contusion of the occipital region. Eeturned to duty September 3d, 1862. Elwood, Solomon, Private, Co. A, 8th New York Cavalry, aged 25 years. Contusion and denudation of the frontal bone by a conoidal musket ball. Fisher’s Hill, Virginia, October 7th, 1864. Eeturned to duty March 15th, 1865. Foote, G. W., Corporal, Co. E, 51st Pennsylvania Volunteers. Gunshot contusion and denudation of the right parietal bone. Antietam, September 17th, 1862. Eeturned to duty June 17th, 1863. Foster, S. M., Private, Co. E, 13th North Carolina Eegiment. Gunshot contusion of the skull. Chanccllorsville, Virginia, May 3d, 1863. Eeturned to duty. Funk, John, Corporal, Co. I, 54th Pennsylvania Volunteers, aged 39 years. Contusion of the parietal bone by a musket ball. Newmarket, Virginia, May 15th, 1864. Eeturned to duty June 29th, 1834. Gallutia, a. M., Private, Co. H, 53d Pennsylvania Volunteers, aged 26 years. Contusion of the left parietal region by a fragment of shell. Spottsylvania, May 11th, 1864. Eeturned to duty August 26th, 1864. Gardnter, "William, Private, Co. B, 18th Indiana Volunteers. Gunshot contusion of the left parietal bone. Vicksburg, Mississippi, June 1st, 1833. Eeturned to duty August 17th, 1863. Glynn, Joun, Private, Co. G, 57th New York Volunteers, aged 35 ycais. Gunshot contusion of the cranium. Peters- burg, Virginia, June 16th, 1864. Eeturned to duty October 13th, 1864. Hadeield, Michael E., Private, Co. F, 8th Ohio Cavalry, aged 23 years. Contusion of the left parietal bone by a conoidal musket ball. Bunker Hill, Virginia, September 5th, 1864. Eeturned to duty October 28th, 1864. Hamilton, Wji. S., Private, Co. D, 14th New Hampshire Volunteers, aged 21 years. Contusion and denudation of the right parietal bone by a conoidal musket ball. Winchester, Virginia, September 19th, 1864. Eeturned to duty November 28th, 1864. Hyde, Thomas, Private, Co. F, 1st Vermont Cavalry, aged 18 years. Contusion of the bones of the cranium by a frag- ment of shell. Appomattox Court-house, Virginia, April 8th, 1865. Eeturned to duty June 29th, 1865. Jones, Henry, Private, Co. E, 26th United States Colored Troops. Contusion of the parietal bone by a conoidal musket ball. John’s Island, South Carolina, July 7th, 1864. Eeturned to duty February 17th, 1885. Kelley, C. T., Sergeant Major, 20th Kentucky Volunteers. Gunshot contusion of the bones of the cranium. Atlanta, Georgia, J uly 10th, 1864. Eeturned to duty September 21st, 1864. Lakeman, William, employed on the Gunboat Carondelet. Collision of tlie bones of the skull by a fi-agment of shell. Fort Henry, Tennessee, February 0th, 1862. Eeturned to duty May 0th, 1862. Lennon, John A., Private, Co. A, 32d Massachusetts Volunteers, aged 23 years. Gunshot contusion of the bones of the cranium by a conoidal musket ball. Deep Bottom, Virgiida, August 14th, 1864. Eeturned to duty September 22d, 1834. Madore, Edward, Private, Co. M, 11th Vermont Volunteers, aged 17 years. Gunshot eontusion of the right parietal bone by a conoidal musket ball. Cold Harbor, Virginia, June 4th, 1834. Eeturned to duty August 31st, 1864. Martin, Jacob W., Corporal, Co. K, 101st Ohio Volunteers, aged 30 jmars. Contusion of the right parietal bone by a conoidal musket ball. Franklin, Tennessee, November 30th, 1864. Eeturned to duty February 1st, 1835. Monroe, D. S.,- Corporal, Co. H, 20th Michigan Volunteers, aged 24 years. Gunshot contusion of the occipital bone by a musket ball. Petersburg, Virginia, October 28th, 1864. Eeturned to duty December 20th, 1864. Osgood, Charles E, Co. A, 40th Massachusetts Volunteers, aged 32 years. Gunshot contusion of the left parietal bone. Cold Harbor, Virginia, June 3d, 1834. Eeturned to duty March 11th, 1835. Ean, C. C., Private, Co. B, 114th Pennsylvania Volunteers, aged 27 years. Gunshot eontusion of the left temporal bone, with lodgment of the baU, which was extracted soon after the reception of the injury. Gettysburg, July 3d, 1863. Eeturned to duty May Gth, 1864. Eobinson, William, Private, Co. E, 0th United States Infantry. Gunshot contusion of the left temporal bone by a pistol ball. Gettysburg, July 3d, 1803. Eeturned to duty September 4th, 1863. Eoth, Peter, Private, Co. E, 4th United States Artillery, aged 35 years. Gunshot contusion of left frontal. Peters- burg, Virginia, March 31st, 1835. Eeturned to duty July 26th, 1865. Euggles, S. N., Private, Co. B., 157th New York Volunteers, aged 23 years. Gunshot contusion of the left parietal. Chancellorsville, May 3d, 1803. Eeturned to duty January 21st, 1804. Eussell, George G., Private, Co. E, 15th Blaine Volunteers, aged 18 years. Contusion and denudation of the left tem- poral by a conoidal musket ball. Lline Eun, Virginia, November 30th, 1863. Eeturned to duty April 19th, 1864. Eussell, Joseph, Piivate, Co. G, 27th Michigan Volunteers, aged 21 years. Gunshot contusion of the parietal by'a conoidal musket ball. I’etcrsburg, Virginia, July 23d, 1864. Eeturned to duty January 11th, 1805. GUNSHOT CONTUSTONR OF TTTF CFANTAL P.ONRS. 97 Sally, Ciiaiiles IL, Private, 4th Maine Battery. Contusion of the frontal bone by a fragment of shell. Cedar Mountain, Virginia, August 9th, 1862. Returned to duty, April 3d, 1863. SatterlA', MHlliam, Corporal, Co. G, 137th New York Volunteers, aged 43 years. Contusion of the right parietal by a conoidal musket ball. Resaca, Georgia, May 15th, 1864. Returned to duty, June 27th, 1864. Selba', Harlow E., Sergeant, Co. G, 78th Illinois Volunteers. Gunshot contusion of the cranium. Chickamauga, Georgia, September 19th, 1863. Returned to duty, December 1st, 1863. Shattuck, C. H., Private, Co. H, 142d New York Volunteers, aged 44 years. Contusion of the bones of the skull by a conoidal musket ball. Petersburg, Virginia, June 30th, 1864. Returned to duty, September 22d, 1864. Shaw, William, Private, Co. G, 100th Illinois Volunteers, aged 21 years. Gunshot contusion of the skull by a fragment of shell. Kenesaw Mountain, Georgia, June 27th, 1864. Returned to duty, December 6th, 1864. SiiUEA’’, D.AXIEL, Private, Co. C, 148th Pennsylvania Volunteers, aged 26 years. Gunshot contusion and denudation of the mastoid process of the temporal bone. Gettysburg, July 2d, 1863. Returned to duty, September 11th, 1863. Stalmaker, M. W., Sergeant, Co. E, 10th West Virginia Volunteers, aged 33 years. Gunshot contusion of the frontal by a musket ball. Cedar Creek, Virginia, October 13th, 1884. Returned to duty, November 7th, 1864. Stephens, J. N., Private, Co. K, 30th Georgia Regiment. Gunshot contusion of left temporal. Gettysbui'g, Pennsyl- vania, July 3d, 1863. Returned to duty, August 24th, 1864. SUMXER, Jacob, Private, Co. D, 67th New York Volunteers, aged 31 years. Gunshot contusion of right parietal by a conoidal musket ball. Cold Harbor, June 1st, 1884. Returned to duty, August 9th, 1834. Titus, George S., Sergeant, Co. F, 9th New Jersey Volunteers, aged 24 years. Gunshot contusion of the skull by a fragment of shell. Cold Harbor, June 3d, 1884. Returned to duty, December 13th, 1864. Twenty-two cases are reported of gunshot contusion of the cranial bones, in which the patients were discharged or mustered out at the expiration of their terms of service without any serious physical disability. Brief notes of the particulars of these cases are appended : Beateridge, j. G., Captain, Co. F, 2d Rhode Island Volunteers. Gunshot contusion of frontal bone over the right eye. Wilderness, May 7th, 1864. Mustered out of service, June 17th, 1864. Browx, Charles, Sergeant, Co. G, 58th New York Volunteers. Gunshot contusion of the skull. Cross Keyes, Virginia, June 8th, 1^62. Discharged from service, July 13th, 1862. Browx, Patrick, Private, Co. H, 6th Pennsylvania Volunteers. Gunshot contusion of the cranial bones. Second Bull Run, August 29th, 1862. Discharged from service, December 20th, 1862. Creasea', Johx F., Private, Co. I, 124th Illinois Volunteers. Gunshot contusion of left, parietal by a fragment of shell. Vicksburg, June 23th, 1833. Treated at ^lemphis, by Surgeon J. D. Brumley, U. S. V. Returned to duty, and subsequently mustered out of service. Became a pensioner June 29th, 1835, on account of chronic diarrhoea. He died about the 20th of August, 1835, having had, according to the report to the Pension Office of his attending physician, W. D. Yargan, M. D., no head symptoms. Doolittle, Hexry, Private, Co. H, 2d Michigan Volunteers. Gunshot contusion of cranium, with denudation of bone. Near Knoxville, Tennessee, November 16th, 1863. Mustered out of service, July 20th, 1864. Gaa', 5Villiam, Private, Co. A, 2d Ohio Cavalry, aged 20 years. Contusion of the frontal bone by a conoidal musket ball. Petersburg, July 30th, 1864. Treated at Mount Pleasant and Mower Hospitals. Discharged June 13th, 1865. General Order, A. G. O., No. 77, 1865. Head, Albert, Captain, Co. F, 10th Iowa Volunteers, aged 24 years. Gunshot contusion of right parietal by round musket ball. Champion Hills, May 16th, 1863. Treated at Officers’ Hospital, Memphis, Tennessee. Mustered out on expiration of term of service, December 17th, 1864. Hexsler, Charles, Sergeant, Co. F, 6th Wisconsin Voluiiteers, aged 23 years. Denudation of right parietal by conoidal musket ball. Southside Railroad, Virginia, March 31st, 1885. Treated at Lincoln and Harvey Hospitals. Mustered out of service, J uly 10th, 1865. Houtz, James, Private, Co. K, 111th New York Volunteers, aged 19 years. Contusion of the frontal bone by a conoidal musket ball. Petersburg, Virginia, April 2d, 1865. Discharged from service, June 8th, 1865. Kxox, E. B., Major, 44th New York Volunteers. Denudation and contusion of occipital bone by shell. Spottsylvania, May 8th, 1864. Treated at Fifth Corps Hospital, and at Washington, by Surgeon T. Antisell, U. S. V. LeaA^e of absence granted. May 17th, 1864, and mustered out Avith his regiment, October 11th, 1864. Lloyd, William, Private, Co. G, 122d Ohio Volunteers, aged 23 years. Contusion of os frontis by conoidal ball denuding the bone. Accidental, April 15th, 1865. Entirely recovered when discharged, June 9th, 1865. McConnell, James, Private, Co. A, 9th New York Volunteers, aged 25 years. Gunshot contusion of skull by a buckshot. Antietam, Maryland, September 17th, 1832. Discharged at expiration of term of service, April 24th, 1863. 1 .} 98 WOUNDS AND INJUKIES OF THE HEAD, Mouiiian, James, I’l-ivate, Co. C, llOtli 1‘oiiiisylvaiiia Volunteers, aged 20 years. Denudation and contusion of frontal bone by fragment of shell. I’etersburg, June lOtli, 18u4. Treated at Harewood. Mustered out of service, June 21st, 1804. Morton, D. J., IJentenant, Co. O, 143d Pennsylvania Volunteers. Gunshot contusion of the bones of the skull. Wilderness, May (ith, 1804. T'reated at the Fifth Corps Hospital, and at Washington. Mu.st(‘red out with his regiment, Juno 12th, 1805. Murphy, D,VNIEL, Private, Co. A, 21)th Massachusetts Volunteers, aged 54 years. Contusion of the temporal by a fragment of shell. Fort Steadman, Virginia, March 25th, 1865. Treated at DeCamj) and Dale Hospitals. Mustered out of service, September 11th, 1835. Surgeon C. N. Chamberlain, U. S. V., records the case. Plymesser, Samuel J., Sergeant, Co. G, Gth Iowa Volunteers. Gunshot contusion of the skull. Konesaw Mountain, Georgia, June 27th, 1804. Recovered, and was promoted to a lieutenantcy, and, finally, mustered out with his regiment, July 21st, 1865. Sands, E. M., Private, Co. I, 1st Maryland Cavalry, aged 34 years. Contusion of cranial bones by a conoidal musket ball. Treated at City Point and Beverly Hospitals. Discharged on expiration of term of service, September 28th, 1834. Sprague, Thomas C., Sergeant, Co. C, 155th Pennsylvania Volunteers, aged 45 years. Contusion of frontal bone by a conoidal musket ball, the bone being slightly denuded of periosteum. Hatcher's Run, Virginia, March 25th, 1865. Treated at Lincoln, Satterlee, and McClellan Hospitals. Discharged from service, August 14th, 1865. Van Valkenberg, E. P., Co. C, 39th Illinois Volunteers, aged 26 years. Gunshot contusion of left parietal. Peters- burg, April 1st, 1865. Treated at Harewood and Harvey Hospitals. Discharged July 18th, 1865. Waite, Benjajiin, Sergeant, Co. B, 198th Pennsylvania Volunteers, aged 25 years. Contusion of frontal by a conoidal musket ball. Southside Railroad, Virginia, March 31st, 1885. Mustered out of service. May 27th, 1865. Walker, Hugh, Private, Co. L, 5th Iowa Cavalry, aged 19 years. Gunshot contusion of the skull. Fort Donelson, Tennessee, February 15th, 1832. Discharged from service, April 1st, 1863. Way, A. M., Major, 1st New Jersey Volunteers. Denudation of right tempoi-al by a musket ball. Wilderness, May Gth, 1834. Treated by Surgeon Antisell, U. S. V. Mustered out with regiment June 23d, 1834, and pensioned from that date. Pension E.xaminer A. D. Newell state.s, September 1st, 1834, that “The blow was so shocking that he cannot stand excitement or go out in the sun. He is not able to do any -work, but ivill soon improve. His disability is total, and likely to continue about six months.” E.xamiuing Surgeon J. G. Stearns reports to th§ Pension Bureau, December 12th, 1834, that “The patient is one-fourth incapacitated, though less every month.” Ill twenty-eight cases of gunshot contusion of the cranium, the patients were furloughed when convalescent, and no further accounts of them appear : Allen, C. A., Private, Co. E, 18th North Carolina Regiment. Gunshot contusion of the cranium. Chancellorsville, May 3d, 1833. Treated in Hospital No. 23, Richmond, Virginia. Furloughed June 2d, 1863. Aihens, L., Lieutenant, Co. I, 9th Georgia Infantry. Gunshot contusion of the right temporal region. July 4th, 1864. Furloughed July 14th, 1834. Surgeon J. B. Read, C. S. A., reports the case. Bryan, J. L., Sergeant, Co. E., 11th Florida Regiment. Gunshot contusion of the frontal bone. Treated at Howard Grove Hospital, Richmond. Furloughed August 9th, 1864. Collins, J., Private, Co. A, 1st Minnesota Battery, aged 27 years. Gunshot contusion of the frontal bone. October 10th, 1884. Furloughed November 1st, 1834. Cooper, M. A., Private, Co. E, 4th Alabama Infantry. Gunshot contusion of the temporal bone. Wilderness, May 5th, 1864. Treated at Howard Grove Hospital, Richmond. Furloughed June 3d, 1884. Corsey, William, Private, Co. I, 47th Alabama Regiment. Gunshot contusion of the skull. Treated at Howard Grove Hospital, Richmond. Furloughed June 6th, 1834. Cowart, J. L., Corporal, Co. E, 10th Georgia Battalion. Gunshot contusion of the frontal bone. Farmville, Virginia, May 27th, 1864. Furloughed June 14th, 1864. De Gray, Jame.s, Lieutenant, Co. G, 1st Minnesota Volunteers. Gunshot contusion of the cranial bones. Gettysburg, July 3d, 1833. Leave of absence granted him on August 15th, 1833. Edwards, D. R., Private, Co. A, 12th Georgia Regiment. Gunshot contusion of the skull. Chancellorsville, May 3d, 1833. Furloughed June 6th, 1833. Fannin, A. B., Lieutenant, Co. F, Gist Alabama Infantry. Gunshot contusion of the cranium. Winchester, Virginia, September 19th, 1834. Treated at Hospital No. 4, Richmond, Virginia. Furloughed September 29th, 1864. Foley, John W., Sergeant, Co. C, 124th New York Volunteers. Gunshot contusion of the cranium. Chancellorsville, May 3d, 1883. Furloughed July 10th, 1833. Forbes, S. F., Private, Co. K, 7th Tennessee Regiment, aged 21 years. Gunshot contusion of the frontal bone. Wilder- ness, May 6th, 1884. Furloughed May 8th, 1834. Gilbucl-, J. M., Pi'ivate, Co. K, 43d Alabama Regiment. Gunshot contusion of the skull. Wilderness, May 7th, 1864. Furlouglied May 26th, 1864. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 99 llarpcr, E. F., I’rivate, Co. F, IGtli Georgia Regiment. Gunshot contusion of the skull. Chancellorsville, May 3d, 1833. Furloughed July 1st, 1863. Hensley, John C., Captain, Co. G, 59th Alabama Infantry. Gunshot contusion of temporal bone. Wilderness, May Gth, 1864. Furloughed from Howard Grove Hospital, Richmond, Virginia, May 23th, 1864. Hutchinson, R. M., Private, Co. F, 24th Virginia Cavalry, aged 30 years. Contusion of the right parietal by a conoidal musket ball, October 7th, 1834. Treated at Chimborazo Hospital, Richmond. Furloughed October 20th, 1864. Jones, J. J., Lieutenant, Co. B, 13th Virginia Regiment. Gunshot contusion of the cranium. Treated at Jackson and Howard Grove Hospitals, Richmond. Furloughed J une 2d, 1864. Knijht, Jeff., Private, Co. D, 8th South Carolina Infantry. Gunshot contusion of the frontal bone. Treated at Howard Grove Hospital, Richmond. Furloughed August 7th, 1863. Lucas, B., Private, Co. H. 17th North Carolina Regiment. Gunshot contusion of the frontal. Petersburg, Virginia, J une 18th, 1864. Treated in hospital at Farmville. Furloughed July 1st, 1864. McLear, D. B., Lieutenant, Co. I, 24th North Carolina Regiment. Gunshot contusion of the bones of the skull. Trt'ated at Howard Grove Hospital, Richmond. Furloughed May 25th, 1864. Mansell, S. V., Private, Co. E, 6th Florida Regiment. Gunshot contusion of the skull. Treated at Howard Grove Hos- pital, Richmond. Furloughed June 10th, 1864. Saunders, E. P., Private, Co. D, 12th Mississippi Regiment. Gunshot contusion of the parietal. Furloughed June 20th, 1864. Surgeon F. M. Palmer, P. A. C. S., recorded the case. Shcaley, J. M., Private, Co. K, 1st South Carolina Regiment. Gunshot contusion of frontal bone. Fuiloughed from Jack- son Hospital, Richmond, Virginia, October 29th, 1864, for sixty days. Sherwood, J. J., Private, Co. E, 3d Alabama Regiment. Gunshot contusion of skull. Wilderness, May 5th, 1864. Fur- loughed May 25th, 1884, from Howard Grove Hospital, Richmond. Sydnor, T. IF., Lieutenant, Co. G, 4th Virginia Cavalry. Gunshot contusion of right temporal bone, August 13th, 1884. Furloughed from No. 4 Hospital, Richmond, August 25th, 1864. Surgeon J. B. Read, C. S. A., recorded the case. Walker, A., Private, Co. A, 43d Alabama Regiment. Gunshot contusion of the frontal. , Treated at Howard Grove Hos- pital, Richmond. Furloughed August 11th, 1884. Whitley, J. J., Private, Co. C, 8th Alabama Regiment. Gunshot contusion of the parietal. Wilderness, Virginia, May 5th, 1864. Furloughed May 30th, 1864, for sixty days. Wiley, Jacob S., Corporal, Co. K, 18th South Carolina Infantry. Gunshot contusion of right parietal. Petersburg, May 20th, 1864. Furloughed June 13th, 1884. Six patients recovered without serious disability, and were transferred to the Provost Marshal, or exchanged, or were paroled or released. Bodman, Hardy, Private, Co. K, 2d North Carolina Regiment, aged 21 years. Contusion of the occipital by a conoidal ball, which entered near the upper portion of the left ear, and ploughed under the scalp for three inches. Kelly’s Ford, Novem- ber 7th, 1863. Treated at Lincoln Hospital, Washington, till December 7th, thence transferred to Old Capitol Prison for exchange. Bullock, N. B., Private, Co. G, 5th Alabama Regiment. Contusion of right parietal bone by a conoidal musket ball. Win- chester, Virginia, September 19th, 1864. Transferred for exchange, October 25, 1864. Galloway, J. T., Private, Co. E, 25th North Carolina Regiment, aged 34 years. Contusion of frontal bone by a conoidal musket ball. Hatcher’s Run, Virginia, April 1st, 1885. Released June 14th, 1865. Glenn, Wade M., Private, Co. A, 14th Tennessee Infantry, aged 25 years. Gunshot contusion of occipital bone. Peters- burg, Virginia, April 2d, 1865. Transferred to Old Capitol Prison for exchange, April 17th, 1885. Fisher, John H., Private, Co. E, 33th North Carolina Regiment. Contusion of the frontal bone by a fragment of shell. Fort Fisher, North Carolina, January 15, 1885. Transferred to Provost Jlarshal, April 8th, 1865. Woodburn, IF., Private, Co. K, 43d North Carolina Regiment. Gunshot contusion of the skull. Gettysburg, July 3d, 1863. Treated at DeCamp Hospital, New York Harbor. Paroled September 5th, 1863. Nine patients, with gunshot contusions of the cranium, deserted from hospital, and it may be inferred that their disabilities were not of a serious nature. Diffexbacu, P., Private, Co. A, 7th New York Volunteers, aged 33 years. Contusion of the occipital by a six-pound k’on ball. Antietam, September 17th, 1832. Treated at Camden Street, Baltimore. Deserted December 4th, 1862. Eddy, Axoxzo F., Private, Co. 1, 18th Massachusetts Volunteers, aged 25 years. Gunshot contusion of the skull. Wil- derness, May 5th, 1864. Treated at Corps, Campbell, and Beverley Hospitals. Deserted October 15th, 1864. Glenx, Jacob, Private, Co. K, 1st Pennsylvania Rifles, aged 35 years. Contusion of the occipital bone by a fragment of shell. Petersburg, Virginia, June 17th, 1864. Treated at Division, Mount Pleasant, ainl York Hospitals. De.sorted October 20th, 1864. 100 WOUNDS AND INJUEIES OF THE HEAD, Hasselriss, William, Private, Co. C, 93th Penn.sylvatiia Volunteers, aged 30 years. Contusion of the frontal bone by a fragment of shell. Cedar Creek, Virginia, October 19th, 1834. Treated at Division and Cuyler Hospitals. Deserted January 8th, 1865. Hoffm.an, Henry, Private, Co. K, 7th Ohio Volunteers, aged 23 years. Contusion of right temporal by a conoidal mus- ket ball. Chancellorsville, May 3d, 1833. Treated at Douglas and Cincinnati Hospitals. Deserted November 16th, 1863. McCall, James, Private, Co. A, 147th Pennsylvania Volunteers. Contusion of the temporal by a fragment of shell. Gettysburg, July 3d, 1833. Treated at Seminary and Satterlee Hospitals. Deserted September 15th, 1833. McElroy, James, Private, Co. F, 33th Wisconsin Volunteers, aged 40 years. Contusion of the frontal bone by a conoidal musket ball. Petersburg, Virginia, June 24th, 1834. Treated at Division, Lincoln, and York Hospitals. Deserted September 20th, 1864. Eyan, Thomas, Private, Co. H, 58th Massachusetts Volunteers, aged 35 years. Contusion of left temporal by a conoidal musket ball. Cold Harbor, June 3d, 1834. Treated at Ninth Corps Field, Harewood, and Mower Hospitals. Suffered on exposure to the sun. Deserted Deccnnber 2d, 1864. WiSPERT, Adaji, Private, Co. H, 91st Pennsylvamia Volunteers, aged 23 years. Gunshot contusion of the occipital. Petersburg, Virginia, June 18th, 1834. Treated at Division, Lincoln, and Satterlee Hospitals. Deserted August 9th, 1864. Ill ten instances, men in whom this form of injury had been diagnosticated, recovered and were returned to modified duty in the Veteran Reserve Corps, in accordance with a General Order from the Adjutant General’s Office. On their discharge, at the close of the war, four of them were pensioned, and six had no disabilities. The disabilities of the four pensioners appeared to have been of a sliglit nature, limited to pain and headache on exposure. Barnes, John K., Private, Co. C, 23d Illinois Volunteers, aged 27 years. Contusion of the skull by a conoidal musket ball. Winchester, Virginia, July 24th, 1834. Treated at Jarvis and Mower Hospitals. Transferred to Co. 118, 2d Battalion of the Veteran Eeserve Corps, January 19th, 1865. Not on Pension Roll. Hastings, T. J., Private, Co. E, 3d Vermont Volunteers, aged 18 years. Contusion of the frontal bone by a fragment of shell. Cold Harbor, Virginia, June 3d, 1834. Treated at Lincoln, McKim’s, and Brattleboro’ Hospitals. Transferred to Co. G, 2d Veteran Eeserve Corps, November 23th, 1864. Discharged July 18th, 1865. Pension Examiner C. S. Cahoon, of Lynden, Vermont, reported, on February 17th, 1837, that this man then complained of giddiness and pain in the bead. Heeler, William C., Corporal, Co. E, 2d Pennsylvania Heavy Artillery, aged 20 years. Contusion of tbe frontal by a fragment of shell. Petersburg, Virginia, August 2d, 1834. Treated at Field and Satterlee Hospitals. Transferred to the Vet- eran Eeserve Corps, 2d Battalion, January IGth, 1865. Mustered out November 21st, 1865, and pensioned in April, 1867. Pen- sion Examining Surgeon E. Simington reported that this pensioner suffered from congestion of the brain on slight exposure to the sun or fire beat, and rated his disability at one half, and probably not permanent. AIcCarthy, J., Private, Co. A, 42d New York Volunteers, aged 20 years. Contusion of the frontal by a fragment of shell. Gettysburg, July 2d, 1833. Treated at Field and Satterlee Hospitals. Transferred to Veteran Eeserve Corps, December 13th, 1833. Mustered out, on expiration of term, June 27th, 1864. Pension Examining Surgeon E. A. Smith reported, Decem- ber 6th, 1865, that this man was a pensioner and suffered from headache. McLarney, P., Private, Co. G, G9th New York Volunteers, aged 40 years. Contusion of the right temporal by a conoidal musket ball, destroying the sight of the right eye. Cold Harbor, Virginia, June 3d, 1864. Treated at Fairfax Seminary and Mower Hospitals. Transferred to the Veteran Eeserve Corps, January 28th, 1865. Discharged July 8th, 1865, and pensioned. Died in 1868. Oberholtzer, S. W., Private, Co. G, 55th Ohio Volunteers, aged 33 years. Contusion of the parietal by a conoidal musket ball. Chancellorsville, Virginia, May 3d, 1883. Treated at Field, Alexandria, Satterlee, Patterson Park, and Camp Dennison Hospitals. Transferred to the Veteran Eeserve Corps, November 17th, 1863. Discharged for disability, October 27th, 1834, and pensioned from that date. Eingwald, W. a.. Private, Co. E, 24th Michigan Volunteers, aged 19 years. Gunshot contusion of the occipital. North Anna, Virginia, May 23d, 1834. Treated at Field, Fairfax Seminary, Haddington, and St. Mary’s Hospitals. Transferred to the 2d regiment Veteran Ee.serve Corps, August 31st, 1834. Discharged July 17th, 1885, and name not found on Pension Roll. Egberts, E. A., Private, Co. E, 20tb Indiana Volunteers, aged 15 years. Contusion of the left parietal by a fragment of shell. Petersburg, Virginia, June 16th, 1834. Treated at Division and Lincoln Hospitals. Transferred to the 9th regiment Veteran Reserve Corps, December 8th, 1884. Not on Pension Roll. Sharpie, Francis, Private, Co. B, 60th New York Volunteers, aged 19 years. Contusion of tbe occipital by a conoidal musket ball, which lodged in the back of the neck. Gettysburg, July 2d, 1833. Treated at Satterlee Hospital, where the missile was extracted on September 18th. Transferred to the 9tli regiment Veteran Reserve Corps, December 31st, 1863. Not pensioned. Walsh, Michael, Private, Co. K, 5th Connecticut Volunteers, aged 21 years. Contusion of the right parietal bone by a conoidal musket ball. Cedar Mountain, Virginia, August 9th, 1832. Transferred to Co. 21, 2d Battalion Veteran Reserve Corps, September 1st, 1833. Mustered out, on expiration of term of service, July 22d, 1864. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 101 The patients named in the following list were discharged from service on account of serious disabilities, the nature of which was not specified : He:mpton, E. JI., Co. B, 3(1 New Hampshire Volunteers. Gunshot contusion of the parietal region. Morris Island, South Carolina. Discharged from s'ervdce November 11th, 1833. Surgeon A. J. H. Buzzell, 3d New Hampshire Volunteers, regarded the disability as total. Noyes, Samuel G., Sergeant, Co. A, 40th Massachusetts Volunteers, aged 22 years. Gunshot contusion of left temporal bone, by a conoidal musket ball. Cold Harbor, Virginia, June 3d, 1834. Treated at Field, Slough, York, Boston, and Read- ville hospitals. Discharged fi-om the latter, Novemher 17th, 1834, for disability resulting from injury to skull. O’Brien, J., Private, Co. C, 28th Massachusetts Volunteers. Gunshot contusion of the skull. Treated at Carver Hos- pital. Discharged from service March 14th, 1833. Disability considered as total. Many of the cases of gunshot contusion of_ the cranial bones were followed by very grave symptoms. Hsemorrhage, erysipelas, and gangrene were the early complications of the superficial portions of the wounds ; periostitis, caries, and exfoliation often resulted from the injury to the bone ; and, in some instances, the mischief extended to the membranes or to the brain itself. The remote effects included persistent pain in the point struck, vertigo, chronic irritation of the brain, mental imbecility, epilepsy, and impairment of the special senses, especially by amaurosis and deafness. Hcemorrhage . — Of the cases belonging to this category, one was complicated by primary, one by secondary hoemorrhage, and a third, by haemorrhage in connection with extensive sloughing. The brief notes of these cases are as follows ; Newco.mbe, John S., Private, Co. E, 50th New York Volunteers. Contusion of the left temporal by a ball accidentally discharged from his own musket on the Battery at New York City, September 18th, 1831. The temporal artery was partly divided and there was profuse haimorrhage. When taken to the hospital he was insensible. The artery was still bleeding. It was ligated near the zygoma. He died September 21st, 1831, from intiammation of the brain. White, John F., Lieutenant, Co. C, 134th Pennsylvania Volunteers. Contusion, by a shell fragment, of the right pari- etal bone, near the sagittal suture. Fredericksburg, December 13th, 1832. Treated at Field, Point Lookout, and Philadelphia Officers’ hospitals. Free haemorrhage, on two occasions, from branches of the temporal. The bleeding was arrested by com- pression. There was burrowing of pus and an abscess formed near the ear. The wound healed bj' the end of January, and the patient returned to duty on February 17th, 1833. Brooks, John, Private, Artillery, aged 37 years. Gunshot contusion of the temporal. Admitted, August 11th, 1833, to the Louisiana Hospital at Richmond, under the care of Assistant Surgeon II. N. Young, C. S. A. The scalp wound was in a gangrenous condition, and soon after a profuse hajmorrhage took place from the posterior auricular artery. This recurred repeat- edly, though temporarily controlled by pressure, and death took place on September 15th, 1833. Erysipelas . — Six of the cases of gunshot contusion of the skull are reported to have been complicated by erysipelas. Two of these cases were fatal : Baker, John C., Private, 104th Ohio Volunteers, aged 22 years, was wounded, at the battle of Franklin, Tennessee, November 30th, 1884, by a conoidal ball, which caused a flesh wound of the left side of the head. He was conveyed to Nash- ville, and thence sent to Jeffersonville, Indiana, on January 11th, 183.5, suffering from erysipelas. On February 23d, he was transferred to Lincoln Hospital, Washington, D. C., and, on June 17th, 1885, was mustered out of service. Gildersleeve, Wai., Corporal, Co. D, 40th New York Volunteers, aged 23 years, was wounded, in the engagement near Petersburg, Virginia, March 25th, 1835, by a conoidal musket ball, which entered the scalp over the lamboidal suture and cross- ing the occipital bone obliquely, emerged three inches from the wound of entrance, grazing the bone in its passage. Ho received, at the same time, a wound of the little finger of the left hand. He was, on the following day, admitted to the hospital of the 2d division. Second Corps, and, on March 27th, was transferred to the Finhiy Hospital, Washington, D. C. On admission, the symp- toms were favorable; but, on March 31st, coma, with stertorous breathing, supervened. S-inapisms were applied to nape of luick, wrists, and ankles, and, on the following day, consciousness returned, and the patient felt much improved. On April 4th, erysip- elas of the scalp set in, and on April 18th, symptoms of pneumonia appeared; but from April 26th, he gradually recovered and was returned to duty on December 8th, 1835. He was pensioned for one year. Pension Exam'ming Surgeon M. D. Benedict reported, August, 183-5, that his disabilities would not be permanent. King, George D., Private, Co. I, 21st Michigan Volunteer.s, was wounded, at the battle of Stone River, December 31st, 1862, by a musket ball, which struck behind the left ear and lodged under the scalp, lying against the bone.'- He was sent to Hospital No. 7, Louisville, Kentucky. On January 1.5th, 1833, erysipelas supervened. He gradually recovered, and on April 1.5th, he was transferred to Hospital No. 19. On the 27th, he was readmitted to Hospital No. 7. Four months after the reception of the injury the ball was e-xtracted. The sense of hearing was entirely do.stroyed. lie was di.scharged from service for disability 102 WOUNDS AND INJUEIES OF THE HEAD, rated at oue-lialf, on Jilay 16th, 1863. Surgeon J. L. Teed, 38th Illinois Volunteers, and the Adjutant General of Michigan, and Acting Assistant Surgeon W. W. Goldsmith report the ease. A year subsequently, Pension Examining Surgeon Geo. W. Hears, reports that the wound was still discharging slightly. There was, probably, a scale of the outer table detached. Thompson, Jacob, Cook, 11th Illinois Cav.alry, aged 26 years, was wounded at Fort Pillow, Tennessee, April 12th, 1864, by two musket balls, one of which crossing the vertex of the cranium, inflicted a scalp wound and contused the bone. He was conveyed to Mound City Hospital, Illinois, on April 16th. Erysipelas of the head supervened and an abscess formed under the integuments, which caused much pain and febrile reaction. The abscess having been opened, the patient steadily improved, and on May 20th, 1864, Surgeon Horace Wardner, U. S. V., reports that he was returned to duty entirely cured. Whitlock, George H., Private, Co. G, 109th Illinois Volunteers, aged 37 years, was wounded befoi-e Petersburg, July 30th, 1864, by a musket ball, which tore up the scalp in the temporal region, and denuded the skull. First treated at the field hospital of 3d division of the Ninth Corps, he was transferred, on August 2d, to the Mount Pleasant Hospital at Washington. Tlie register of this hospital states that the outer table was indented but not fractured. Erysipelas of the scalp set in, and the case termin.ited fatally on December 1st, 1864. Wright, S. C., Private, Co. G, 8th Florida Regiment, Was, on October 2d, 1863, admitted to Cliimborazo Hospital at Rich- mond, Virginia, with a gunshot wound of the scalp with contusion of the skull. An attack of erysipelas supervened; but tliis was readily subdued. After this, the patient sufl'ered from acute dysentery. He died from tliis complication on December 5th, 1863. Surgeon J. B. McCaw, P. A. C. S., reports the case. Gangrene . — Two cases of gunshot contusion of the cranium were complicated by sloughing of the scalp ; both ultimately recovered : Allen, George H., Sergeant, Co. G, 146th New York Volunteers, aged 20 years, was wounded, at the battle of Gettys- burg, Pennsylvania, July 2d, 1863, by a piece of shell, which tore the scalp over the right pai’ietal, to the extent of two inches, denuding the bone of periosteum. He was admitted to the field hospital of the 2d division of the Fifth Corps, and, on the 10th, transferred to the Satterlee Hospital at Philadelphia, Pennsylvania. Phagedenic action in the wound was promptly arrested by a lotion of nitric acid. Some exfoliation of the bone occurred in the progress of the case. The patient recovered and was returned to duty on the 23d of September, 1863. His name does not appear on the Pension List. The case was reported by Acting Assist- ant Surgeon J. B. Trenor. Smith, J. W., of Captain Randolph’s Company of Louisiana Infantry, was wounded, at the battle of Chancellorsville, May 2d, 1863, by a gunshot projectile which lacerated the scalp and contused the skull. He was conveyed to Richmond and placed in the Louisiana Hospital. Erysipelas, followed by gangrene, supervened. Detergent lotions were applied, and after a while the wound presented a healthy granulating surface, and eventually cicatrized. The patient Vv^as furloughed on June 3d, 1863. Periostitis . — In a few instances protracted inflammation of the contused pericranium was observed : Coffey, Patrick, Prlv'ate, Co. E, 37th New York Volunteers, received, at the battle of Williamsburg, Virginia, May 5th, 1862, a gunshot wound of the scalp with injury to the occipital bone. He was, on May 11th, admitted to the Mill Creek Hospital, and, on May 22d, was sent to the Ladies’ Horae Hospital, New York, whence he was returned to his regiment. He was, how- ever, readmitted on June 12th, 1863, and was discharged from the service on June 23d, 1863. The injury to the bone was trivial probably. No application for pension appears on the rolls of the Interior Department. Harrick, Charles, Private, Co. D, 94th New York Volunteers, aged 25 years, received, at Gettysburg, July 3d, 1863, a contusion of the right parietal bone at the lower posterior angle, by a conoidal musket ball which lodged under the integuments. He was admitted to Satterlee Hospital, Philadelphia, on July 10th, and, on the following day, the position of the ball was detected by a probe and the missile was extracted. A slight scale of the outer table necrosed, and the pericranium was inllamed for a while; but the wound ultimately did well, and the soldier was returned to duty December 3d, 1863. His name is not found on the Pension List. Lusk, S.\muel R., Sergeant, Co. E, 137th New York Volunteers, aged 28 years, received, in the engagement on the Wauhatchie River, Tennessee, October 28th, 1863, a gunshot contusion of the right portion of the occipital bone. He was, on the following day, admitted to Hospital No. 3, Chattanooga. He probably, shortly afterwards, returned to duty, as in June, 1864, he was again admitted to the field hospital of the 2d division. Twentieth Corps, suffering from the old injury. He was, on June 18th, sent to Hospital No. 2, Chattanooga, Tennessee, on June 20th, to the Cumberland Hospital, Nashville, on June 27th, to the Brown Hospital, Louisville, Kentucky, and on July 1st, to Camp Dennison, Ohio, whence he was returned to duty on July 18th, 1864. He was discharged on June 28th, 1865. Examining Surgeon J. G. Orton reports, April 19th, 1869, that this pensioner Was nervous, sleepless, depressed in spirits, and able to work but little. Pr.\tt, Thomas D., Private, Co. D, 18th Massachusetts Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot wound of the head. He was admitted to the hospital of the 3d division. Second Corps, and, on December 16th, was sent to the hospital at Point Lookout, Maryland. Here it was ascertained that the right temporal bone had become necrosed. On May 1st, 1863, the patiimt was sent to the West’s Buildings Hospital, Baltimore, Maryland, and, on May 18th, to the Lovell Hospital, Portsmouth Grove, Rhode Island, where he was transferred to the Veteran Reserve Corps, on July 18th, 1863. His name is not on the Pension Rolls. GUNSHOT CONTUSIONS OF THE CEANIAL BONES. 103 Exfoliation . — This was frequently observed in gunshot contusions of the skull. Many examples are noticed in the categories of other complications. The following twenty-seven cases were also reported : Brown, C., Private, Co. F, 11th South Carolina Battery, received, on July SOth, 18G4, a gunshot -vvound of the scalp, with probable contusion of the bone. He was admitted into the Jackson Hospital at Bichmond, Virginia, on Sei)tember 16th. Exfoliation resulted, and, after the separation of a scale of bone, he recovered. Ckinyan, James, Private, Co. H, 14th Connecticut Volunteers?, aged 48 years, received, at the battle of the Wilderness, May 5th, 1884, a contusion of the skull, by a conoidal musket ball. He had already been wounded at Chaucellorsville, in the left hand, and at Gettysburg, over the left knee, and he was somewhat lame from the latter injury, while the former had caused luxation of the thumb. He was sent to Washington, on May 11th, having been treated meanwhile at the field hos]ntal of the 2d divusion of the Second Corps. He was removed, on June 28th, to Summit House Hospital, Philadelphia, on July 17th, to Knight Hospital, New Haven, and, on October 17th, to the hospital at Eeadville, Ma.ssachusetts, whence he was discharged on March 10th, 1865. During his sojourn at Eeadville, an exfoliation of the outer table of the skull took place. He was pensioned, and in June, 1835, Pension Examining Surgeon J. Cumminskey, reported that he suflered from headache and dizziness, and was unfit for the Veteran Eeserve Corps. DiEitL, George, Private, Co. E, 100th New York Volunteers, aged 27 years, received, in the engagement at Chester Station, Virginia, May 12th, 1834, a gunshot contusion of the left parietal near the temporal suture. On May 15th, he was admitted to Hampton Hospital, and, on May 18th, he was sent to the hospital at Point Lookout, thence, on July 12th, to Judiciary Square Hospital at Washington, and, on July 18th, to the Sisters of Charity Hospital, Buffalo. The outer table of the bone had exfoliated, and the w'ound was granulating and looking well, when, on August 16th, typhoid fever set in, and the case terminated fatally on August 23d, 1864. Dur/ffins, JR., Private, Co. C, 11th South Carolina Eegimeut, received, on June 18th, 1864, a gunshot contusion of the left parietal bone. He was admitted to the Confederate hospital at Farmville, Virginia, on June 21st. The external table of the parietal bone exfoliated; otherwise the case did well, and the patient was furloughed on July 8th, 1864, for sixty days. Fauck, Albert, Private, Co. K, 94th Pennsylvania Volunteers, aged 20 years, was wounded, in a skirmish near the Eappahannock, by a buckshot, which entered the scalp over the vertex of the cranium and lodged near the skull. The missile w'as extracted on the same day. On September 1st, he was admitted to the Camden Street Hospital, Baltimore. Some slight exfoliation, not involving the entire thickness of the outer table, took place; and then the w'ound healed kindly, and, on October 11th, 1862, the patient was sent to the Convalescent Camp at Fort McHenry, Baltimore, for duty. The case is reported by Acting Assistant Surgeon Edmund G. Waters. His name does not appear on the Pension Eolls. Georr/e, J. JR., Private, Co. B, 9th Louisiana Eegiment, received on April SOth, 1863, a gunshot wound of the head. He was admitted to the Louisiana Hospital, Eichmond. The external table of the bone was contused and exfoliated, yet the case progressed favorably, and, on June 10th, 1863, the patient was furloughed. Goldey, James H., Private, Co. A, 90th Pennsylvania Volunteers. Supposed gunshot scalp wound ov(!r occipital. Antietam, September 17th, 1832. Entered hospital at Washington, September 23d. Transferred to Fort Schuyler Hospital, New York, October 7th. Transferred to Fort Hamilton, December 1st. On December 13th, he entered the Satterlee Hospital, Philadelphia, complaining of pain hi the occipital region. The .wound was closed, but it reopened on DecemlKu- 18th. On Jannary 18th, 1863, a circular portion of dead bone, an inch in diameter, was detected by a probe. The patient had no pain or derangement of the mental faculties, and walked actively about the ward. About February 2d, the discharge from the wound was profuse, and the necrosed bone had not separated. There was no change in his condition until February 25th, when the exfoliation was observed to be loose, and it was removed by Acting Assistant Surgeon J. N. ilooi’e, through a crucial incision. The exfoli.ation consisted of a portion of the external table, an inch in diameter, and several smaller pieces. On March 3d, yet another piece of the external table was removed. On March 17th, the wound was nearly healed. The patient felt entirely well; and on May 22d, 1863, he was discharged from service. He aj>pears to have had no subsequent trouble, since his name does not appear on the list of applicants for pension. Haxdletox, George W., Private, Co. D, 95th Pennsylvania Volunteers, aged 30 years, was wounded at the battle of Cold Harbor, Virginia, June 2d, 1864, by a conoidal musket ball, which contused the frontal bone. He was conveyed to Alexandria, and admitted into the 3d Division Hospital on .June 6th, and from there sent to the York Hospital, I’ennsylvania, on .June 14th, 1864. He recovered, .and was discharged from service on .January 12th, 186.5. In a communication dated .January, 1868, the Commissioner of I’ensions states that Handleton receives a pension of foiu- dollars per month, his disability being rated one-half and temporary. On December 20th, 1865, Examiniiug Surgeon Z. Eeed reported that portions of the outer table of the frontal bone had exfoliated, and that a profuse ill-conditioned pus continued to be discharged from the wound. The patient’s general health was much impaired, and about one-half the time he was incapacitated from obtaining his subsistence by manual labor. Kinxe, Charles, Private, Co. G, 108th New York Volunteers. Contusion of right p.ariettd by a musket ball. Antietam, September 17th, 1862. Treated at the field hospital of the 3d division of the Second Corps, until the 20th, and then sent to the Mount Pleasant Hospital at Washington. On November 2d, he was furloughed, and subsequently returned to duty. He was discharged from service at the regimental hospital on December 24tli, 1802. Disability reported as “total,” by Assistant Surgeon Williams Ely, 108th New York Volunteers. He was pensioned, and reported by Pension Examining Surgeon II. M. Montgomery, of Eochester, New York, Janu.ary, 1863, .as having load a series of pieces of bone exfoliated. Doctor Montgomery 104 WOUNDS AND INJUlllES OE THE HEAD stales that the wound was then discharging pus, hut that the patient would probably be free from disability in a few months, and that he appeared “fat and hearty.” In November, 18G5, Pension Examining Surgeon J. K. H3 de reported that this pensioner complained of increase of pain and dizziness on attempting to labor, and that he had applied for an increase of his pension, in a letter from Lancaster, Wisconsin; but no disabilty except dizziness is certified to. In the army such applicants are regarded as malingerers ; but in the civil service a greater latitude prevails. Lir/r/itt, W. B., Private, Co. G, 18th Mississippi Infantry, received a gunshot wound of the scalp in the right parietal region. He was admitted into the Howard Grove Hospital, Eichmond, May 2~th, 1864. Exfoliation of the outer table of the bone resulted. On July 4th, he was furloughed. Lipscomb, IF. A., Sergeant, Co. C, 5th South Carolina Eegiment, was admitted, on June 23d, 1864, to the Confederate Hospital at Farmville, Virginia, with a gunshot injury of the right supra orbital region. Gradual exfoliation of the external table followed. The patient was furloughed on Jul^^ 8th, 1864. Maksh, George H., Private, Co. I, 14th New York Artillery, aged 18 years. Contusion of left pari(4al, near lamb- doidal suture, denuding bone of periosteum. Petersburg, March 25th, 1865. Treated at Mount Pleasant Hospital, Washington; White Hall, Pennsylvania; and was discharged from service June 19th, 1865. In November, 1869, Pension Examining Surgeon J. G. Pitts reports that a fragment of the external table had been exfoliated, and the pensioner alleged that he suffered dizziness when he stooped at work, and he suffered a stinging sensation in hot weather. Dr. Pitts rated the disability at one-quarter, and probably temporary. Maxwell, Thomas, Private, Co. K, 5th Michigan Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot injury of the right side of the cranium, anterior portion. He was, on December 19th, 1862, admitted to the Third Division Hospital at Alexandria. A portion of the outer table exfoliated, otherwise the case progressed favorably, and the patient was returned to duty on May 29th, 1863. His name does not appear on the Pension List. klcGuiRE, JoHX, Private, Co. G, 65th New York Volunteers. Gunshot contusion of the frontal bone. Antietam, September 17th, 1882. Troated at Carver Hospital, Washington. Exfoliation of both tables of the frontal resulted, and the patient suffered from neuralgia. He was discharged from service on October 21st, 1862. His name does not appear on the Pension Rolls. McNicitols, William, Private, Co. K, 69th Pennsjdvania Volunteers, aged 28 years. Contusion of the left parietal by a fragment of shell, which lacerated the scalp for three inches or more. Gettj’sburg, July 2d, 1863. Treated at Mower Hospital, Philadelphia. On August 14th, an exfoliation of the outer table was removed, and the patient recovered and was returned to duty on December 16th, 1833. Case reported by Acting Assistant Surgeon R. II. Lougwill. The man’s name is not on the Pension Roll. Pattersox, Elias, Private, Co. I, 7th Kentucky Volunteers, received, in the engagement before Vicksburg, ^Mississippi, May 22d, 1863, a gunshot contusion of the cranium. He was taken to a field hospital, and, on June 3d, ^vas admitted to the hospital steamer E. C. Wood. On June 8th, he was sent to the Union Hospital, Memphis, Tennessee. Three or four small pieces of the external table of the cranium came away by exfoliation. He was returned to duty by Surgeon J. D. Brumley, U. S. V. On August 20th, he was sent to Fort Pickering, Tennessee, and was there discharged from service, on September 21st, 1863, his disability being rated at one-half; Surgeon Daniel Stahl, 7th Illinois Cavalry, certifying that the portion of the occipital removed was two inches long and half an inch wide, and th.at dimness of sight .and various nervous affections followed the injury, and that the soldier was not fit for the Veteran Reserve Corps. Patterson is pensioned at four dollars per month. SCAXLAX, Jonx, Private, Co. D, 164tli New York Volunteers, aged 33 years, was hit, .at the battle of North Anna, M.ay 18th, 1864, by a fragment of shell, over the middle of the left lambdoidal suture. Treated at field hospital of 3d division. Second Army Corps, Carver Hospital, Washington, and Mower Hospital, Philadelijhia. At the latter hospital the wound reopened, and several exfoliations of the outer table came away. On August 25th, this soldier was returned to duty by Surgeon J. H. Hopkinson, U. S. V. He was discharged July 17th, 1865, and pensioned from that d.ate. On J.anu.ary 16th, 1866, Pension Examining Surgeon J. E. King reported that his dis.ability was permanent, and that he had dizziness and pain in the head, especially when in a stooping posture, and that he could not endure the sunlight. Sheffler, Johx, Priv.ate, Co. D, 45th Pennsylv.ania Volunteers, aged 44 years, received, at the battle of Cold Harbor, Virginia, June 3d, 1864, a gunshot flesh wound of the head. He was on the same day admitted to the hospit.al of the 2d division. Ninth Corps, on June 10th, 1864, sent to the Emory Hospital, Washington, D. C., on April 9th, sent to the Cuyler Hos- pital, Philadelphia, and, on Jlay 10th, transferred to the Mower Hospital, where he was disch.arged from the service on June22d, 1865, on account of gunshot contusion of the cranium. Pension Examining Surgeon Edward Smitli reports, July 20th, 1865, that the ball injured the frontal and right p.arietal bones, and tlnat several exfoli.ations of bone had been removed; that the patient complained of constsint headache and dizziness, .and the ex.aminer rated his disability at “three-fourths, .and probably permanent.” Soloman, TF. S., Private, Co. G, 66th North Carolina Regiment, wms, on June 20th, 1864, admitted to the Confederate Hospital at Farmville, Virginia, with a gunshot injury of the frontal bone, received on June 18th, 1864. Gradual exfoliation of the outer table took place, but the patient did well, and was, on July 8th, 1854, furloughed. Stafford, Bexjamix, Private, Co. I, 26th New York Volunteers, w'as admitted to the Fairfax Seminary Hospit.al, Virgini.a, September 29th, 1862, with a gunshot wound over the right side of the frontal bone, received at Antietam. He was returned to duty May 8th, 1863. It was found, however, that the outer table of the os front is was exfoliating, and the man was discharged from the service on May 28th, 1863. He was examined at Utica for a pension, by Dr. H. B. Day, April 22d, 1864. It was found th.at two fi'agments of bone had exfoliated, and that there was a fistulous sinus through which detached bone could still be felt. 4 * Med, a Surs. of Ihc War of t]ie Rebenioii, Pfjrt 1. Vol 1 CoTj). A.H. Beam , ( See page 121. • 2. 1*1 W.Wlieeler,( Seepage 225.) 4- Ft . D. SuUhmn , ( Seepage 148.) 3.Pt. P. Scott, ( Seepage 105.) PLATE III. GUNSHOT SCALP WOUNDS AND CONTUSIONS OFTHE SKULL. GUNSHOT CONTUSIONS OF THE CHANIAL BONES. 105 Scott, Pembroke, Private, Co. D, 198tli Pennsylvania Volunteers, aged 25, was wounded, in an engagement at Gravelly Run, Virginia, March 29th, 1835, by a conoidal ball, which inllictcd a wound in the scalp, three inches in length, across the left temporal and edge of the left parietal bone, and contused the outer table of the latter. He was conveyed to the field hospital of the 1st division. Fifth Corps, and thence was transferred to City Point, Virginia, where he remained in the depot field hospital of the Ninth Corps until the 2d of April, when he was transferred to the Harewood Hospital, Washington, D. C. By April 29th, the wound was doing well and healing kindly, and there were no indications of depression nor compression. On May 15th, he was transferred to the Satterlee Hospital, Philadelphia, Pennsylvania. On June IGth, several small pieces of the outer table of the skull were removed. The patient improved gradually, and was, on the 6th of July, 1835, discharged from service. The appearance of the wound, while the man was at Harewood Hospital, is exhibited in the third figure of Plate HI. Scott was pensioned to date from July 5th, 1835. In April, 1836, Pension Examining Surgeon Wilson Jewell reported that the man’s nervous system was much affected, and that loss of memory and partial aphasia were especially noticeable. Dr. Jewell regarded the disability as permanent. Tree, Fr.vnklix, Private, Co. A, 20th Maine Volunteers. Contusion and denudation of the vault of the skull for one inch by a musket ball. Gettysburg, July 3d, 1833. Treated at Seminary and Satterlee Hospitals. A scale of bone exfoliated. The wound then healed, and the man was returned to duty October 23d, 1833. His name is not on the Pension Roll. Whitmer, B. M., Captain, Co. G, 3d South Carolina Battalion, received, at the battle of Gettysburg, Pennsylvania, July 2d, 1863, a gunshot scalp wound, with contusion of the cranium. He was admitted to the Confederate Hospital No. 10, Richmond, Virginia, Exfoliation of the external table of the bone took place. Captain Whitmer was furloughed on July 20th, 1833. Wilson, J. P., Lieutenant, Co. B, 9th Virginia Regiment, received, at the battle of Spottsylvania Court-house, Virginia, May 10th, 1834, a gunshot injury of the left parietal bone. The wound of the scalp was about two inches in length. He was, on May 24th, admitted to the Confederate hospital at Farmville, Virginia. An exfoliation of the bone took place, otherwise the case progressed favorably, and the patient was furloughed on July 1st, 1834. He was readmitted on October 1st, 1864, suffering from acute dysentery and icterus, and returned to duty on October 29th, 1864, by Surgeon H. D. Taliaferro, C. S. A., the medical officer in charge of the general hospital at Farmville. The injury of the head gave no further trouble. mi WiLSOX, Jarvis C., Sergeant, Co. I, 10th Wisconsin Volunteers, aged 21 years. Contusion of the occipital by a conoidal musket ball, which lodged beneath the scalp below the semi-circular ridge. Kenesaw Mountain, Georgia, June 29th, 1864. The missile was extracted on the field by Assistant Surgeon R. G. James, lOth Wisconsin Volunteers. Treated at Totten Hospi- tal, Louisville, till August 26th, at Harvey Hospital, Madison, Wisconsin, till October 25th, and then sent to Milwaukie to be mustered out. Pension Examiner C. F. Falley reports. May 24th, 1839, that there had been exfoliation of the external plate of the occipital, and that the muscles inserted into the curved lines of the occipital were indurated and contracted. The head was drawn backward somewhat, and the pensioner alleged that bending it forward caused dizziness and pain. He was totally dis- abled for manual labor; but Doctor F'alley thought that he would ultimately improve. [In October, 1873, Examiner C. F. Falley, of Ja Lancaster, Wisconsin, reported a slight depression at the seat of injury, and that the patient suffered from vertigo and cephalalgia.] Gilkey, Francis W., Private, Co. K, 10th Pennsylvania Reserves, was wounded in one of the earlier battles of the war, and made a prisoner. In January, 1863, he was exchanged, and received at the Annapolis General Hospital. He had, to the right of the vertex, a large ulcer, resulting from a gunshot wound of the scalp, extending over the sagittal suture. Tlie skull was necrosed, and probably there had been denudation, with contusion of the bone. Erysipelas supervened, followed by gangrene. When this was arrested, exfoliation took place, and the brain was exposed. The fragment of the skull exfoliated is represented in the adjoining wood- cuts (Figs. 30 and 31), copied at natural size from the specimen for- warded by the attending physician. Dr. A. V. Cherbonnier. Granu- lations sprang up, the wound closed, and the patient recovered without any further complications. He was discharged from service on Jan- uary 29th, 1863. His name does not appear on the Pension Rolls. Jill Fig 30. — Exfoliation from the parietals following gunshot contusion. Spec. 5587, Sect. I, A. M. M. a Fig 31. — Interior view of the foregoing specimen. Hay, John W., Private, Co. D, 61st Pennsylvania Volunteers, aged 29 years, was wounded, at the battle of Spottsyl- vania, Virginia, May 11th, 1834, by a conoidal ball, which struck obliquely about the middle of the forehead. He was admitted to the hospital of the 2d division. Sixth Corps, but the injury must have been considered slight, as no record of the case was found until July 12th, when the patient was admitted to 5Iount Pleasant Hospital, on account of a gunshot scalp wound near the occipital protuberance, subsequently received in General Early’s demonstration against the diTences of Washington, the day of the patient’s admission. Gangrene attacked this later wound. Bromine, nitric acid, yeast, and charcoal poultices were suc- cessively applied to the gangrenous wound. The sloughing was checked, and the wound soon assumed a healthy appearance. The wound on the forehead was not affected by gangrene, and was supposed to bo trifling, and was treated witli simple dress- ings. A month after his admission, the man complained of some pain in the forehead. Ice water was applied, and morphia was given internally. Death occurred a few hours afterwards. On August 7th, 1831, at \lvi post mortem examination, the brain was 14 106 WOUNDS AND INJUKIES OF THE HEAD, found, to be slightly congested, but no pus was observed between the skull and dura mater; yet the latter was detached from the inner table of the skull, which was carious over a surface nearly as large as the surfaceof the incijjient exfoliation on the outer table. The scale of dead bone of the outer table remained in situ. The dura mater opposite the diseased inner table was thickened and had depos- its of lymph on the surface next the cranium; other- wise, the encephalon was normal in appearance. The specimen was con- tributed by Assistant Sur- geon C. A. McCall, U. S. A., and is represented in • the foregoing wood-cuts. Fig. 32. — .Segment of os fronfis, showing necrosis fol- EiGS. 3'2 and 3.3. The FIG. 33. — Internal view of the same specimen, showing the lowing a gun-shot contusion. .Sjocc. 29G4, Sect. I, A. M. M. yp fpg were . Malvern Hill, Viiginia, July 1st, 18G2. Treated at Carver Hospital, Washington, and returned to duty August 13th, 1862. On November 12th, 1862, he was admitted to Episcopal Hospital, Philadelphia, under the care of Doctor W. S. Forbes. He was suffering from severe local paili at the seat of injury. He was discharged from the service on February 25th, 1863. His name does not appear on the Pension Roll. Ereneter, Charles J., Captain, 7th United States Colored Artillery, received, at the capture of Fort Pillow, Tennessee, April 12th, 1864, a gunshot wound of the anterior portion of the temporal ridge of the right parietal bone. At the end of four months the wound had closed, but it opened again spontaneously several times. There was always more or less pain extending backwards from the seat of injury, nearly parallel with the median line. With every change to bad weather the pain would become intolerable, and exposure invariably aggravated it. Captain Epeneter resigned on March 16th, 1865. Hants, Enoch W., Private, Co. C, GthNew Jersey Volunteers, aged 23 years, was wounded, at the battle of Kinston, North Carolina, December 14th, 1862, by a conoidal musket ball, which apparently only involved the scalp. He was admitted to the Stanlej' Hospital at Newberne on the 20th, whence he was furloughed and sent north in February, 1864. On the 8th of April, 1864, he was admitted into the Balfour Hospital, Portsmouth, Virginia, still sufiering from the wound in the head. In the latter })art of April he was ti'ansferred by steamei- to the De Camp Hosjiital, in New York Harbor, where the case is reported as a contusion of the skull. He was returned to duty on May 27th, 1864, but was again admitted to the Hampton Hospital, at Fort Monroe, on June 11th, 1864, suffering from cephalalgia. On June 21st, he was transferred to the Mower Hospital at Philadelphia, and finally sent to Trenton, New Jersey, on September 22d, 1864, to be mustered out of service. His name does not appear on the Pension List. Hayes, William A., Private, Co. A, 28th ISIassachusetts Volunteers, received a slight wound of the scalp by a fragment of shell, with contusion of the skull over the sagittal suture. Fredericksburg, December 13th, 1862. Treated at Point Lookout till May 1st, 1863, West's Building, Baltimore, till May 9th, Lovell Hospital, Rhode Island, till October 7th, 1863, when he was transferred to the 2d Battalion of the Veteran Reserve Corps. He suffered greatly from pain in the cicatrix, which, on May 13th, 1867, was reported bj^ the pension examiner to be very sensitive on pressure. It was paiticularly painful in warm weather and after exposure to the sun. King, Samuel, Private, Co. H, 49th Pennsylvania Volunteers, aged 33 years, received, at the battle of Cold Harbor, Virginia, June 4th, 1864, a severe wound of the left side of the scalp by a conoidal musket ball. He was admitted into the Soldiers’ Rest Hospital at Alexandria, June 6th, and a few days later sent to Philadel])hia, and admitted, on June 16th, into the 16th and Filbert streets Hospital. On July 16th, he was sent to the Satterlee Hospital. He suffered from constant pain in his head. The wound healed gradually. On September 29th, he was transferred to Camp Curtin at Harrisburg, and, on October 6th, 1864, returned to duty. The case is reported by Surgeon I. I. Hayes, U. S. V. Lacoste, S. D. M., Sergeant, Co. K, 23d South Carolina Regiment, wms admitted to the South Carolina Hos]iital, Charlottesville, Virginia, September 6th, 1862, with a gunshot injury a little to the left of the median line and midway between the eye and the root of the hair. There was an indentation of the bone, but no perceptible fracture. The periosteum w'as gone to the extent of about one square inch. No operation was performed. In July, 1863, the man was at his home, not yet recovered, and suffering constantly with intense pain in the head, regretting that he had not been opei-ated upon. The case is reported by Assistant Surgeon B. W. Allen, P. A. C. S. Marshall, James, Private, Co. H, 28tli Pennsylvania Volunteers, received, at the battle of Antietam, Maryland, September 17th, 1862, a gunshot injury of the frontal bone. He was, on October 30th, 1862, admitted to the Carver Hos[)ital, Washington, D. C., and, on January 6th, was transferred to the Patterson Park Hospital, Baltimore. He was treated in the hospitals of the latter city for cephalalgia and neuralgia, until August 29th, 1863, when he was returned to duty. Rate, Edivard, Private, Co. C, 17th New York Volunteers, aged 21 years, was wounded, at the battle of Fredericks- burg, Virginia, December 13th, 1862, by a fragment of shell about two inches in length, which produced a wound of the scalp on the left side of the head. He was prostrated, and, in this condition, immediately conveyed to a field hospital, where his wounds were dressed. After the troops reerossed tlie river, he was sent to Point Lookout, Maryland, where he was admitted to Hammond Hospital, on December 16th. He suffered for one month from a severe pain at the point struck, and also, after his entering the hospital, from a malarial fever, to which was attributed the slow manner in which the wound healed. He was transferred, on February 13th, 1863, to New York, and there admitted on the 17th, to Ladies’ Home Hospital, where he remained until returned to duty on March 30th, 1863. Eussell, TT. P., Private, Co. L, 6th Alabama Regiment. Gunshot contusion of the left parietal, received at the battle of 1' air Oaks, May 31st, 1862. Nenralgia supervened, and constant pain in the cicatrix for a long period after the injury. The patient was examined by Surgeons Wolford, Thom, and Cabell, of the Confederate service, and for a long time he was unfit for duty. He finally recovered, and returned to duty March 5th, 1833. Young, Thomas, Private, _Co. F, 17th United States Infantry, received, at the battle of Antietam, September 17th, 1862, a gunshot contusion of the vertex. Treated at Washington and Baltimore, and discharged February 14th, 1863. He was pensioned, and, in September,- 1886, Pension Flxamining Surgeon F. I’. Fitch, of Milford, New Hampshire, reported that ho had continuous pain in the cicatrix, a very irritable temper, and impaired memory. Vertigo. — Dizziness, giddiness, or vertigo, are among the commonest complaints of the pensioners who liave recovered from contusions of the skull. The cases of Hastings (p. 100), ot Kinnc (p. 103), of Marsh, Scanlan, Shefller (p. 101), and of Wilson (p. 105), have been 108 WOUNDS AND INJURIES OF THE HEAD already cited. In the following cases, also, this result is specially commented on by the surgeons from whose reports the abstracts have been compiled : Blood, J. C., Private, Co. G, 27tli Missouri Volunteers, received a contusion of the right frontal eminence by a conoiJal musket ball, at the siege of Vicksburg, June 17th, 18G3. He was discharged from service July 9th, 1865, and pensioned. On January 19th, 1866, he was reported by Doctor J. T. White, at Edina, Missouri, as suffering greatly from vertigo, being entirely un6t to labor at his trade of brick-laying. Galmish, George, Private, Co. H, 150th Pennsylvania Volunteers. Gunshot contusion of the right parietal, at Gettysburg, July 2d, 1883. Treated at Gettysburg and Philadelphia, and discharged from service September 28th, 1863, and pensioned. At this date. Pension Examining Surgeon H. Lenox Hodge reports that during his treatment this man had suffered from convulsions, with much cerebral disturbance, and was then troubled with impaired vision and hearing, and had an unsteady gait and constant dizziness and vertigo, and rated his disabilities at three-fourths, and probably temporary. Kellogg, L. M., Private, Co. B, 14th New York State Militia, aged 29 years, received, at the battle of Gettysburg, Pennsylvania, July 1st, 1863, a gunshot wound of the left occipital region by a musket ball. He was admitted into the field* hospital on the same day, and subsequently transferred to New York, and admitted, on July 27th, into the Central Park Hospital. He suffered from headache and vertigo. Simple dressings were used. He gradually recovered, and was returned to duty, November 29th, 1863. Leighton, Charles W., Corporal, Co. E, 11th New Hampshire Volunteers, aged 23 years, was wounded at the battle of Petersburg, Virginia, June 16th, 1864, by a conoidal musket ball, which contused the occipital bone. He was admitted to the hospital of the 2d division. Ninth Corps, and thence conveyed to Annapolis, Maryland, and admitted, on the 20th, into the First Division Hospital. After several transfers, ho was admitted into the Webster Hospital, in New Hampshire, on December 2d. On May 27th, 1865, he was discharged from service. In March, 1868, the Commissioner of Pensions reported that this man’s disability was rated at one-half and permanent, and that he had been greatW troubled with vertigo since the reception of the wound. Magness, W. a.. Musician, Co. B, 5th Maryland Volunteers, aged 29 years, was wounded in front of Petersburg, July 6th, 1864, by a conoidal musket ball, which tore up the pericranium over the right p.arietal protuberance. Treated at field hospital of the Eighteenth Corps, Balfour Hospital, Lovell Hospital, Patterson Pai'k Hospital, and Hicks Hospital, and discharged from service June 27th, 1865, and pensioned. On August 29th, 1869, Pension Examining Surgeon A. W. Dodge reported him as totally disabled, his suffering from vertigo and cephalalgia being aggravated by chronic diarrhoea ; but his disabilities were not regarded as permanent. Shuler, D. A., Corporal, Co. K, 2d South Carolina Infantry, received a gunshot contusion of the cranium. He was admitted into the Chimborazo Hospital, No. 3, Richmond, on February 22d, 1863. Vertigo and general debility resulted from the injury. On February 26th, he w.as furloughed. WOODBORNE, George W., Sergeant, Co. B, 13th Ohio Cavalry, aged 31 years. Contusion of the right parietal, near the sagittal suture, by a conoidal musket ball. Deep Bottom, Virginia, August IGth, 1864. Treated at Ninth Corps Field, Beverley, and White Hall Hospitals. Discharged May 19th, 1865. In April, 1868, he was a pensioner, and his disability was regarded as permanent. Pension Examining Surgeon W. F. Sharp reported that he was much troubled with vertigo, pain in the head, and partial loss of memory. Headache . — Ten cases are reported, in which, after gunshot contusions of the skull, headache was the most troublesome symptom. To these might he added the cases of McCarty (p. 100), and Crinyan (p. 103) : England, Samuel, Sergeant, Co. C, 9th Pennsylvania Reserves, was wounded at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a buckshot, which entered about the centre of the occipital region. He was admitted to the field hospital of the 3d division. Fifth Corps, on the day of the receipt of injury, and, on the following day, was sent to the field hospital at Gettysburg, whence he was transferred, on the 7th, to Satterlee Hospital at Philadelphia. Although the patient stated that the ball was still in the wound, it healed kindly. Dnring the progress of the case, he complained of headache. He remained in hospital until April 27th, 1864, when he was returned to duty. Haynes, Owen, Private, Co. C, 28th Massachusetts Volunteers, aged 27 years, was wounded at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal musket ball, which divided the scalp in the right occipital region for a distance of two and a half inches, grazing the skull. He was at once admitted to the hospital of the 1st division, Second Corps, and, on June 11th, sent to the Turner’s Lane Hospital, Philadelphia. His general health was good, but he suffered considerable pain in the head. The wound, which gaped very much, healed gradually, the headache ceased, and, on September 11th, 1863, the patient was returned to duty. The case is reported by Acting Assistant Surgeon David Burpee. Heljireich, Peter, Private, Co. A, 44th Illinois Volunteers, aged 29 years, received, at the battle of Peach Tree Creek, Georgia, .July 20th, 1864, a gunshot contusion of the right parietal region. He was admitted into the field hospital of the 2d division. Fourth Corps, on the same day, and, a few days later, was sent to the general field hospital. On July 27th, the patient was sent to Nashville, and admitted into the Cumberland Hospital. On August 6th, he was transferred to Louisville, and admitted into the Brown Hospital, and, subsequently, to the Mound City Hospital, in Illinois. The wound was discharging, and he had occasional headache. On September 24th, he was admitted into the general hospital at' Quincy. He was discharged from service, June 10, 1865. The case is reported by Surgeon Horace Wardner, U. S. V. The name of this patient does not appear on the Pension List. GUNSHOT CONTUSIONS OF THE CEANIAL BONES. 109 Lake, Joshua, Sergeant, Co. B, 2(1 Delaware Volunteers, aged 19 years, received, at tlie battle of Antietam, Maryland, September 17tli, 1862, a gunshot contusion of the right parietal. He was admitted, on Se])tember 24th, to Walnut Street Hosj>i- tal, at Harrisburg, and, from there, transferred on the 27th, to Philadelphia, where he was first admitted to Race Street Hospital, and there remained until January 14th, 1833, when he w'as transferred to Mower Hospital. During the progress of the case, the patient complained of headache, the cause being attributed to the wound. On February 2d, a part of the ball, still remaining lodged, was removed, after which he did well, and, on the 25th of the same month, was able to do light duty, in the performance of which he was engaged at the latest report. Laughlin, Josiah D., Private, Co. G, 91st Ohio Volunteers, aged 16 years, was wounded in an engagement at Win- chester, Vir^nia, J^.ily 20, 1834, by a revolver ball, which contused the skull at the junction of the sagittal and lambdoidal sutures. He was admitted into the hospital at Cumberland, Maryland, July 23d. There was cephalalgia and slight impair- ment of audition. The wound healed rapidly under the application of simple dressings, and the patient was returned to duty, August 18, 1864. McCletng, George W., Private, Co. G, 12th West Virginia Volunteers, aged 22 years, was wounded, March 0th, 1804, by a pistol ball, which entered the scalp near the intersecting angle of the frontal, parietal, and temporal bones on the left side, and made its exit four inches above the meatus auditorious externus, two inches from point of entrance, and contused the skull. Admitted to hospital at Cumberland Maryland, He had headache and i-inging in the ear, which continued for some days. He was returned to duty, May 26th, 1804. Moakly, E., Private, Co. A, 14th New York State Militia, aged 26 years, received, at the battle of Gettysburg, Pennsyl- vania, July lst-3d, 1863, a gunshot contusion of the skull. He was, on July 0th, admitted to the Cuyler Hospital, Germantown, Pennsylvania. The injury was painful and caused much headache, and at times the patient was delirious. In a few weeks the wound began to heal, and in September it had closed. The patient was returned to duty on February 10th, 1804, but he still complained of much headache after exertion. The case is reported by Acting Assistant Surgeon C. E. Prall. Nason, Alexander, Corporal, Co. C, 1st Alabama Artillery, aged 28 years, was wounded at the capture of Fort Pillow, Tennessee, April 12th, 1834, by a conoidal musket ball, which struck the right side of the head, immediately above the ear, con- tusing but not fracturing the bone. He was, on April 14th, admitted to the hospital at Mound City, Illinois, and for weeks he suffered from headache, restlessness, and fever. On May 18th, he had entirely recovered, and, June 22d, 1864, He was returned to duty. Spurr, William E., Sergeant, Co. A, 56th Massachusetts Volunteers, aged 23 years, received, in an engagement before Petersburg, Virginia, June 17th, 1834, a gunshot contusion of the skull. He w'as taken to the hospital of the 1st division. Ninth Corps, and, on June 30th, sent to the Mount Pleasant Hospital, Washington, where he was treated for concussion of the brain. On July 22d, he was transferred to the Mower Hospital, Philadelphia, Pennsylvania. He was then suffering from headache. He was discharged from the service on January 30th, 1865, on account of phthisis pulmonalis. His name does not appear on the Pension List. Weiss, Francis S., Private, Co. F, 54th Pennsylvania Volunteers, aged 27 years, was wounded, in an engagement near Piedmont, Virginia, June 5th, 1864, by an explosive musket ball, which tore a triangular flap, horizontally, about two inches in length and one inch above the occipital protuberance, and contused the bone. The wound was first dressed, on June 7th, by Assistant Surgeon Reuben Hunter, 54th Pennsylvania Volunteers, who extracted five or six fragments of the ball, which were imbedded beneath the integument, and applied cold water dressings. He was admitted into hospital at Cumberland, Maryland, on June 20th, and on June 23d the wound was nearly cicatrized; suppuration had ceased, and the general symptoms were good, with the exception of an occasional headache. The patient's appetite and digestive powers were unimpaired. On July 20th, he left the hospital on furlough, but, not returning, was reported as a deserter, August 3d, 1864. His name does not appear on the Pension Rolls. Chronic Irritahilitij of the Brain . — The cases of Hefler (p. 100), and of Lusk (p. 102), and several of those of which abstracts are given further on, under the heading Mental Aberration, were examples of that condition described as cerebral irritation, characterized at the outset by restlessness and a general tendency to persistent flexion of the voluntary muscles, with contraction of the pupils, cool surface, feeble and slow pulse, and mental irritability, and, subsequently, by mental decay or complete fatuity, by paralysis or epilepsy. This condition has been supposed to be associated with lacerations of the gray matter of the brain. The following case was regarded as an example of this pathological condition at the time, though the autopsy proved that it was accompanied liy grave structural lesions : Farniiam, Noah L., Colonel, lltli New York Volunteers (1st Fire Zouaves), was wounded, at the battle of Manassas, July 21st, 1861, by a musket ball, which made a superficial forward wound over the left p.arietal. lie was much stunned, and fell from his horse. He was conveyed to the E Street Infirmary, Washington, and placed under the care of Assistant Surgeon W. .1. H. White, U. S. .V. The wound Inialed promptly, and his condition was hopeful until August 10th, when gr.ave cerebral symptoms appeared, terminating in liemipl(!gi;i, follnwod by coma and death on August lltli, 1861. At the autojisy, made by no WOUNDS AND INJURIES OF THE HEAD Assistant Surgeon J. W. S. Gouley, U. S. A., an abscess, the size of an English walnut, was found at the seat of injury, with extravasation of blood in the neighboring sulci of the brain. The following description of this case was prepared by Surgeon John A. Lidell, U. S. V. U * * * “It cannot be doubted that, in at least some instances, this ecchymosis, this extravasation of blood beneath the visceral arachnoid membrane into the meshes of the i)ia mater (connective tissue), denotes a genuii^e contusion of the brain or spinal cord, as the case may be; and that, in this way, a positive pathological lesion, perceptible to the unaided vision, is super- added to the concussion. These cases of concussion, complicated with contusion of the nerve tissue, when the cerelirum happens to be tbo part involved, exhibit a marked tendency to the occurrence of meningo-cerebral inflamination and cerebral abscess. The following case strongly corroborates this statement: * * Colonel Farnham, of the New York City Fire Zouaves, was wounded, at the battle of Manassas, July 21st, 1881, by a spent ball, which hit his head and knocked him off his horse. He was picked up insensible. The wound was small in size, superficial in character, and situated on the left side of the head, three inches above thFmeatus auditorius. It healed without any difficulty. The principal symptoms in his case, until near the close, were referable to concussion and irritation of the brain. He died on the evening of August 14th, twenty-four days subse(iuent to the inlliction of the injury. It was thought that he would recover, until about four days before death. He was p?irtially para- lyzed on the right side (hemiplegia) toward the last. He was comatose in the last moments. At the autopsy, made August 15th by Doctor Gouley, U. S. A., we found that the external wound was superficial; that the skull was not injured; that there was copious subarachnoidian effusion; that there was an unusual quantity of yellow-colored serum in the ventricles, and that there was an abscess of the cerebrum, situated directly beneath the wound of the scalp. This abscess was about the size of an English wal- nut, superficial in situation, and surrounded by softened cerebral tissue. The visceral and parietal arachnoid over the abscess were glued together, to some extent, by adhesive inflammation, so that, in endeavoring to turn back the dura mater while making the autopsy, though it was carefully done, the abscess was torn open. There were also traces of an extravasation of blood, three or four weeks old, in the sulci of the bruin, beneath the visceral arachnoid membrane over the seat of the abscess, and likewise at the anterior extremity of the left cerebral hemisphere. There was a flattened clot of blood, black in color, and apparently three or four weeks old, in the fossa, at the base of the middle lobe of the left cerebral hemisphere. The dura mater, in relation with it, was somewhat thickened, roughened, and opacified.” * * * Medical Inspector F. H. Hamilton, U. S. A., has described this case as follows : f “First, I would remark, that you may have an injury of the scalp of an exceedingly trivial character, which may, in the end. prove fatal. A ball may simply tear off the hair of the scalp, and create a very slight abrasion of the skin, yet, the bone being so near, and the brain so close to the bone, it is very probable that serious mischief has been done. The bone in that situ- ation may be so injured as to lead to necrosis, or a sufficient shock may be given to the brain and its envelopes to biing on inflam- mation. I will mention a very remarkable illustration of this fact. Colonel Farnham, after the death of Colonel Ellsworth, took command of the 1st Zouave Regiment. At the battle of Bull Run, July 21st, 1861, he received an injury of the character referred to, and which I e.xamined myself. It was a very slight and supei-ficial wound, which seemed to have taken off very little more than the hair. He was transferred from the field to the Washington Infirmary, where he was reported as doing very well, the wound being considered as a very slight and insignificant one; but, notwithstanding all this, he kept his bed. He did actually seem to be improving until about the ninth day after the reception of the wound, when grave symptoms suddenly supervened, and, in a day or two after, he died. I should notice that, during all the time he was in the hospital, he was very easily disturbed by visitors, and it was his desire to be left alone, showing that there was some cerebral disturbance. I ought also to mention that he was ill before he received the wound, and was unfit to perform duty at the time the battle took place; but, being a gallant officer, he was determined to lead his regiment to the charge. But his previous condition I do not think had much, if anything, to do witii his death, which, in my opinion, and in the opinions of many other surgeons who saw him, was due dii’ectly to the apparently slight wound which he received during the fight.” * * “Next, I called your attention to those injuries of the scalp proiluced by smaller missiles; for example, where a rifle ball had slightly impinged upon the surface of the scalp, producing a slight abrasion of the integument, which accident is usually accompanied by some degree of concussion, either to the skull, to the meninges of the brain, or to the brain itself and which I have said you are not to regard as trivial accidents. Although the patient may not seem to have suffered any severe injury, you are to anticipate that sooner or later there may be an ulceration along the track of the ball, or that there may result necrosis, or meningitis, or cerebritis, and that the patient may ultimately die. And I cited, as an illustration of injuries of this class, the case of Colonel Farnham, who assumed command of the Ellsworth Zouaves after the death of Colonel Ellsworth. He received an injury of such a character, which was exceedingly slight and superficial. I saw him myself, and examined him particularly, and all that was visible was a very trivial scalp wound. He was taken into a hospital in Washington, and there I saw him again, at the expiration of seven or eight days. He was then very irritable, and had been quite ill, but still his friends all thought that his recovery was certain. Throe or four days after this, if I remember correctly, the synqjtoms became more grave, and he died, evidently from the injuries which his brain had received.” * * * Meningitis . — This formidable affection was one of the most common causes of deatli after gunshot contusion of the cranium : Cutting, A. H., Private, Co. K, 13th Massachusetts Volunteers, was wounded, at the battle of Gettysburg, July 2d, 1863, by a conoidal musket ball, which caused a contusion of the frontal bone, just above and external to the right parietal eminence. He was admitted to Camp Letterman, and thence was sent to the McDougall Hospital, New York, on July 12th. Meningitis supei-vened, and death ensued on July 30th, 1863, twenty-seven days from the reception of the injury. The specimen AtMrican Journal of the Medical Sciences, vol. xlviii, p. 323. t Americafi Medical Times, vol. viii, pp. 711-85. GUNSHOT CONTUSIONS OF THE CRANIAL RONES. Ill is copiwl in the adjacent wood-cut (Fig. 34). The injiiml portion of the externa! table is porous and spongy, and a small scale of bone was evidently in process of exfoliation. The internal table shows no trace of injury beyond the most trivial discoloration. The specimen and notes of the case were contributed by Acting Assist- ant Surgeon A. E. M. Purdy. Johnson, C. K., Captain, Co. F, IGth Massachusetts Volunteers, received, at Gettysburg, July ‘Jd, 1863, a scalp wound from a mini6' ball, which produced a con- tusion of the cranium. He was taken to the field hospital of the 2d division of the Third Corps, when meningitis supervened, and he died on Jidy 17th, 1863. Larkins, Daniel, Private, Co. H, 188th Pennsylvania Volunteers, aged It) years, received, at the battle of Cold Harbor, Virginia, June 3d, 1864, a gunshot scalp wound, with contusion of the left parietal. He was can ied to the hospital of the Eighteenth Corps, and, on June 6th, was transferred to the Ilarewood Hospital at Wasliington, and thence, on June 11th, to the convalescent hospital, Philadelphia, where ho died, on June 26th, 1864, from meningitis, following the wound of head. Morris, James, Private, Co. I, IbOth Pennsylvania Volunteers, was admitted, on July 12th, 1863, to the McDougall Hospital, Fort Schuyler, New York, with compression of the brain, following a gunshot wound of the scalp, with contusion of the skull. He died on July 18th, 1863. Thurman, C., Private, Co. E, 42d Pennsylvania Volunteers, was, on Jlay 30th, 1863, admitted to a hospital in Richmond, Virginia, with a gunshot wound of the scalp, involving the cranium. He died on January 7th, 1864, of pneumonia and meningitis. Waterman, William A., First Sergeant, Co. H, 1st Michigan Cavalry, aged 27 years, was wounded, in the action at Salem Church, Virginia, May 28th, 1864, by a conoidal musket ball, which struck the frontal region and laid the bone bare for one inch. He was admitted into the field hospital of the 1st division, cavalry corps, on the same day. The patient was transferred to the Mt. Pleasant hospital, Washington, on June 1st. Simple dressings were used. Meningitis supervened, and death resulted June 14th, 1864. Assistant Surgeon C. A. McCall, U. S. A., reported the case. Wright, Harrison, employed in the Quartermaster’s Department, aged 45 years, was wounded, July 15th, 1864, by a fragment of shell, which injured the scalp and contused the skull. He was, on August 15th, admitted to the hospital for colored troops at City Point, Vii’ginia, and, on August 17th, was transferred to the Satterlee Hospital, Philadelph.ia, where meningitis supervened, from which he died on August 26th, 1864. Fig. 34. — Results of contusion of the frontal bone bj’ a conoidal ball, twenty-seven days after the injury. Spec. 1660, Sect. I, A. 3M. M. Encephalitis . — The following cases were recorded, in which the fatal results were due to inflammation of the brain following gunshot contusions of the skull. Other examples will be found among the cases classified further on : Bowdle, Charles W., Co. K, 1st Ohio Volunteers, received, at the battle of Stones River, Tennessee, December 29th, 1862, a gunshot wound, with contusion of the vault of the skull. He was admitted into the No. 1 Hospital, Nashville, on January 9th. Death resulted April 2d, 1863, from inflammation of the brain. KENNTtDY, Thomas, Private, Co. M, 1st Massachusetts Heavy Artillery, aged 30, was wounded, at the battle of Petersburg, Virginia, June 16th, 1884, by a conoidal pistol ball, which contused the right parietal bone, near the right descending branch of the lambdoidal suture. He was conveyed to Washington, and admitted, on the 21st, into the Lincoln Hospital. Simple dressings were applied, as the injury was considered slight. He was_furloughed on July 16th, but returned on the 29th of the same month. He stated that during his absence from the hospital he had suffered from ague, and, for the last ten days, had experienced a chill daily. A careful examination of the wound was now made, and a roughness of the external table of the skull was detected. He was much prostrated, but complained of no pain or uneasiness about the head. His pulse was frequent and feeble, tongue dry and red, and the abdomen tympanitic and painful. Three grains of calomel, with one-fourth of a grain of opium, were ordered every three hours, until the third dose had been taken ; meantime, tonics and stimulants were given, and afterwards contuiued in liberal doses. Sinapisms were applied to the epigastric region and extremities. No perceptible improvement in his condition, however, was obtained. He died on the afternoon of the 31st, remaining fully sensible and able to answer questions intelligently until within two or three hours of his death. At the autopsy, the seat of injury was found to bo near the middle of the posterior edge of the light parietal bone. The missile had glanced downward and forward, and was found lying against the skull, two inches from the point of injury. The pericranium was S(;parated a distance of three and three-quarter inches along the track of the missile, and beneath it the bone was spongy and porous. The line of separation from healthy bone was well-marked. Upon the removal of the skull-cap, a slight sponginess of the internal table, beneath the pointof impact, was observed. (See Fig. 35.) The meninges, for some distance around the seat of injury, were very much thickened and blackened, and firmly adherent to the calvaria. The brain substance was softened, and the vesscds very much congested. The heart, liver, and spleen were flabby. The case is reported by Acting Assistant Surgeons Dean and Atwater. Fig. 35. — .Showing the extent of necrosis in a calvaria six weeks after a gunshot contusion. Spec. 2320, .Sect. I, A. M. M. 112 W0UN1>S AND INJUEIES OF TIT]': IIl'lAD Eeiimek, William, Private, Co. B, 16th New York Heavy Artillery, aged 44 years, was wounded at Fort Fisher, North Carolina, January 15th, 1865, by a-conoidal musket ball, which contused the frontal and temporal bones. He ^vas taken on board an hospital steamer, and conveyed, on January ‘Jdth, to the McDougall Hospital, New York Harbor, where he died, on February 9th, 1835, from inflammation of the brain. SiiEERON, Tiiojias, Private, Co. A, 15th Virginia Volunteers, aged 20 years, I'eceived, at the battle of Hatcher’s Run, Virginia, March 31st, 1865, a gunshot contusion of the cranium. He was admitted to the hospital of the 2d division of the Ninth Corps, and, on April 3d, was sent to the hospital at Fort Monroe, Virginia. Death occurred on April 16th, 1865, from meningitis and encephalitis. StTNDAY, Jacob C., Cm-poral, Co. C, 34th Illinois Volunteers, was, on May 9th, 1864, admitted to hospital No. 1, Chattanooga, Tennessee, with a gunshot contusion of the skull. He died on June 18th, 1804, from cerebritis. WELCn, CiLAT.LES, Private, Co. D, 8th Maine Volunteers, aged 21 years, was wounded, at the battle of Cold Harbor, Virginia, June 5th, 1864, in the forehead, by a conoidal musket ball, which denuded the os frontis, though producing no apparent fracture. He was admitted to the hospital of the Eighteenth Corps, and thence conveyed to Washington, and admitted, on the 10th, into Harewood Hospital. Tlie case seemed to bo progressing favorably. The patient was sent, on .Tune 10th, to New York City, but, having stopped at Philadelphia on his way, he died suddenly' at a refreshment saloon, on June 21st. 1864. Intracranial Extravasation . — The cases of Colonel Farnham, on p. 109, Private Rea, on p. 120, and that of Private Foster, recorded among the instances of trephining, afford illustrations of haemorrhage within the cranium following gunshot contusions of the skull. Intracranial Abscess . — The following are instances of suppuration following gunshot contusions of the cranium, and other illustrations will he found among the cases of trephining : Crane, Etiian A., Musician, Co. K, 44th New York Volunteers, was wounded, at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket b.all, which struck the frontal bone on the right side, near the median line, and glanced, apparently causing only a flesh wound; the bone was barely bruised. He was admitted to the hospital of the Fifth Corps, and, on June 10th, was sent to the Carver Hospital at Washington. The case progressed favorably until June 20th, when grave cephalic symptoms came on. The patient bec.ame comatose, and died on June 22d, 1864, from cerebral complications. The autopsy revealed a large abscess in the right anterior lobe of the brain, with meningitis beneath the seat of injury. The external table of the bone was slightly discolored and cribriform, while the internal presented a faint attempt at the formation of a circumscribed area of the effects of osteitis. The diploe w.as found of a dark yellowdsh gray color, as in cases of osteomyelitis in long bones. The pathological specimen was sent to the Army Jtledical Museum, and is numbered 1393, in Section I. The specimen and history were contributed by' Assistant Surgeon IT. Allen, U. S. Army. Smith, William, Private, Co. G, 4th New York Heavy Artillery', aged 18 years, was wounded, at the battle of Hatcher’s Run, Virginia, March 31st, 1885, by a conoidal ball, which caused a contusion of the left parietal bone. He was, on the following day, admitted to the hospital of the Second Corps. On April 5th, he was transferred to the Emory Hospital, Wash- ington, D. C., and on April 9th, sent to the Cnyler Hospital, Philadelphia, Pennsylvania. On admittance no osseous lesions could be detected. The case progressed favorably until April 16th, when the patient had two or three slight convulsive pai'oxysms, lying in a somewhat soporose condition during the intervals. He afterw'ards became delirious, and finally almost completely comatose. The muscles of the left side of the body were observed to be in a state of spasmodic contraction and a large collection of pus, formed beneath the left side of tlie scalp, anterior to the wound, and was opened on April 29th. The pathologi- cal condition was supposed to be, that an abscess, resulting from the original shock to the brain substance, was exciting irrita- tion, and would probably eventually burst into one of the lateral ventricles. Mercurials, tartarized antimony, and the fluid extract of veratrum viride were exhibited internally, while the head was kept somewhat elevated. Death ensued on the night of April 30th, 1835, one month from the reception of injury'. An autopsy was made about fourteen hours after death, with the following results : there was no fracture of the skull to bo detected when the scalp was removed, and the bone was not bared beneath the abscess, which has been described as having formed a few hours before death, but was manifestly necrosed just below the origin.al wound. On removing the skull cap it was found that a jdate of bone, about one inch long and three-quarters of an inch broad, had been separated by exfoliation from the inner table, and was adherent to the dui'a mater immediately beneath the position of the original scalp wound. The brain was removed with the membranes entire, but a moderate quantity of blood and serum being found beneath the dura mater and the skull. On reflecting the dura mater of the right hemisphere, the arachnoid ovei- the middle lobe of the cerebrum was found to be acutely inflamcM, presenting an abundant deposit of soft coagulable lymph. The membranes of the left side presented merely a slight pearliness, and the adhesion of the dura mater to the sequestrum, already referred to. The brain substance on the right side was healthy ; on the left side, it was softened beneath the position of the wound, and, at the depth of about three-quarters of an inch, was a small abscess, not larger than a small hickory-nut. All other parts of the body ex’amined appeared normal. The muscular contraction on the same side of the body as the wound was now accounted for by the existence of intracr.ani.al disease upon the opjmsite side. The c.ase is reported by Henry S. Schell, Assistant Surgeon U. S. Army-. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 113 Epilepsy, mental imbecility, derangements of the special senses, and various paralyses were the not infrequent results of gunshot contusions of the cranium. Paralysis. — Twenty-three cases are referred to as attended by this complication ; Adams, J. E., Corporal, Co. F, 15th Massacliusetts Volunteers, received, at the battle of Ball’s Bluff, Virginia, October 2lst, 1831, a gunshot wound of the scalp, with contusion of the right parietal bone. A report of a medical examining board, dated February 20th, 1802, states that there is atrophy of the left arm, with partial paralysis of the sensory nerves and diminu- tion of the temperature. He was discharged from the service, March 8th, 1862. His name is not upon the Pension Rolls. Arend, Johx, Private, Co. F, 46th New York Volunteers, received, at the. battle of South Mountain, Maryland, Septem- ber 14th, 1832, a gunshot wound of the scalp, with contusion of the frontal bone. He was admitted toNo. 1 Hospital at Frederick, on the 17th, and from there, on the 20th, was transferred to Stewart's Mansion Hospital at Baltimore. He was discharged from the service, March 17th, 1833, on which date Assistant Surgeon Ue Witt C. Peters, U. S. A., reports him as being greatly debili- tated, and suffering from spinal irritation, with partial paralysis of the lower extremities, for which, treatment had aflbrded very little benefit. His name does not appear on the Pension List. Bootii, John, Private, Co. E, 55th Pennsylvania Volunteers, aged 29 years, received, at the battle of Drury’s Bluff, Vir- ginia, May 16th, 1834, a gunshot wound of the upper and posterior right parietal region, by a conoidal musket ball. He was taken prisoner, but subsequently exchanged, and admitted, on August 14th, into the First Division Hospital at Annapolis, Mary- land. The patient wa.s afterwards sent to Camp Parole, and, on November 5th, transferred to the general hospital at Pittsburgh. Paralysis of the left log resulted, and he was discharged from service. May 20th, 1865, and pensioned. The case is reported by Assistant Surgeon H. R. Silliman, U. S. A. In August, 1837, Pension Examining Surgeon G. McCook reported that this pen- sioner was totally incapable of earning a living by manual labor, on account of partial hemiplegia, and that his disabilities were j)ermanent. Brown, Presley I., Corporal, Co. B, 102d Pennsylvania Volunteers, aged 24 years, received, at the battle of the Wil- derness, Virginia, ISIay 6th, .1864, a gunshot wound of scalp, a conoidal ball entering at middle of left parietal bone, passing back- wards, making a flesh wound two inches in length, denuding the bone. He was admitted to Lincoln Hospital, Washington, D. C., on May 11th, and, on May 16th, was transferred to Patterson Park Hospital, Baltimore, Maryland; thence, oti May 21st, to hospital at York, Pennsylvania. Acting Assistant Surgeon H. S. Smyser, under whose care the patient came at the latter hospi- tal, reports that the patient stated that there was loss of sensation in right arm and hand from the moment he was struck by the ball. On June 10th, the arm was recovering, and, on June 13th, the patient was transferred to the hospital at Pittsburg, Penn- sylvania, whence he was returned to duty on May 9th, 1865. Busii, Aaron C., Lieutenant, 4th Wisconsin Cavalry, was, in February, 1864, shot in the head, the ball inflicting a scalp wound and contusion of the right parietal, and concussion of brain. He fell from his horse, and was conveyed to the I’egimental hospital very much depressed, but otherwise doing well. The regimental report for March, 1864, states that “Bush is in a fair way of recovery, although a long time will elapse before he will be able to return to duty.” He was discharged on August 30th, 1334, and pensioned for partial hemiplegia of the left side. Carson, J. M., Captain, Co. A, 25th South Carolina Regiment, aged 27 years, received, at the assault on Fort Fisher, North Carolina, January 15th, 1865, by a conoidal ball, a wound of the scalp, with contusion of the skull, causing a paralysis of the right arm. He was admitted, on the 22d, to Chesapeake Hospital, near Fort Monroe, and, on January 30th, was trans- ferred to military prison, after which all trace of him is lost. The case was reported by Assistant Surgeon Ely McClellan, U. S. A. Coohe, B. n., Private, Co. D, 12th Alabama Regiment, was examined, on July 24th, 1862, by Surgeon John G. Moore, 93d Alabama Regiment. He was suffering from an unhealed gunshot wound of the scalp, and probably the skull had been severely contused. He complained of numbness of the left leg. He was reported as unfit for duty. Curry, John, Private, Co. A, 142d Pennsylvania Volunteers, was wounded, at the battle of Fredericksburg, Virginia, December 13th, 1832, by a buckshot, which injured the left parietal bone. He was treated in a field hospital; on December 23d, admitted to the Lincoln Hospital, Washington, D. C., and discharged from the service on February 21st, 1863. His right side and limbs were paralyzed. His name is not on the Pension Rolls. Douglas, Alfred F., Private, Co. I, 6th Vermont Volunteers, aged 19 years, received, at the battle of the Wilderness, Virginia, May 6th, 1864, a wound of the right side of the scalp, by a conoidal musket ball, with contusion of the parietal. He was admitted into the Finley Hospital at Washington, May 11th. Partial paralysis of the lower extremities resulted. On. August 11th, the patient was sent to the Smith Hospital at Brattleboro’, Vermont, and, on September 11th, wfis transferred to the BaxtPi’ Hospital at Burlington. He was returned to duty, November 21st, 1864. The case is reported by Assistant Surgeon S. W. Thayer, U. S. V. Garland, James W., Corporal, Co. G, 5th Wisconsin Volunteers, aged 23 years, was wounded at the battle of Cold Har- bor, Virginia, .June 1st, 1834, by a fragment of shell, which grazed the top of the head, on the median line, about five and a half inches from the margin of the hair on the forehead, inflicting a severe wound of the sealp, about two inches in length by one inch in width, and contusing the cranium. He was unconscious for about ten minutes, the control of the lower e.xtremities was lost, and sensation was impaired. S|)asms and temporary partial paralysis of the U])per extremities supervened. On June 6th, he was admitted to First Division Hosj)ital at Alexandria, Virginia. On .June 28th, he was transferred to McClellan Hospital, Phila- delphia, and thence, on .July 6th, to Turner's Lane Hospital. At the latter date, the patient sufl'ered from severe headache, and the power of motion of the left leg was still impaired, though his general health was good. On July 20th, a small piece of bone 15 114 WOUNDS AND INJURIES OF THE HEAD exfoliated, and was removed. Patient was gradually regaining the use of left leg. On November 15th, the wound was reported as being healed. During the treatment, he had three paroxysms of intermittent fever. The patient was transferred to the Vet- eran Reserve Corps on March 17th, 1835. The case is repot ted by Surgeon Robert A. Christian, U. S. V. He was discharged from service, September 26th, 1835. In 1866, Pension Examining Surgeon J. H. Gallagher reported that he had slight paraly- sis of the left leg, and lieadache and ftiintness on exposure to the sun. Any excitement or study aggravated these symptoms. The examiner regarded these symptoms as likely to increase in severity. Renslcy, H. S., Sergeant, Co. C, loth North Carolina Regiment, aged 24 years, was wounded, on May 22d, 1864, by a conoidal ball, winch inflicted a severe wound of the scalp, and probably, a contusion of the skull. Paralysis of the lower extremi- ties ensued. He was admitted to the field hospital of the 1st division. Fifth Corps, and, on May 29th, was transferred to Mount Pleasant Hospital, Washington; thence, on July 14th, to Lincoln Hospital, whence he was transferred to Old Capitol Prison on August 30th, 1864, and finally exchanged. Ingersoix, Fr.\nk D., Private, Co. E, 26th New York Volunteers, was, on September 24th, 1862, admitted to the Carver Hospital, Washington, D. C., with a shell wound of the head, lacerating the scalp and contusing the outer table of the skull. He was discharged on January 12th, 1863, on account of debility and deranged innervation. His name does not appear on the Pension List. Keser, Wallace, Private, Co. F, 126th New York Volunteers, aged 25 years, received, in the engagement at Harper’s Ferry, Virginia, September 13th, 1832, a gunshot wound in the head, at the junction of the occipital with the parietal bones. He was, on December 29th, admitted to Camp Parole, Maryland. He was subject to vertigo, and suffered from partial paralysis of the right lower limb. He was discharged from service on Januaiy 7th, 1863. He is not reported as being an applicant for a pension. McFoley, James, Private, Co. A, 11th Pennsylvania Reserves, aged 35 years, was wounded at the battle of Spottsylva- nia, Virginia, May 10th, 1834, by a conoidal ball, which passed through the scalp, grazing the left parietal bone near the sagittal suture. He was conveyed to the Mount Pleasant Hospital, Washington, and, on May 19th, was sent to the Camden Street Hos- pital at Baltimore. Hemiplegia of the right side had supervened. He was transferred to Annapolis, June 22d, and, on August 10th, to Pittsburgh, where he was discharged from the service, December 24th, 1864. Paralysis of the right arm still existed. He has not applied for a pension. McKendrick, John P., Co. I, 12th New Hampshire Volunteers, received, at the battle of Chancellorsville, Virginia, May 3d, 1883, a gunshot contusion of the skull, posterior aspect. He was admitted to the field hospital of the 3d division. Third Corps, on the following day, and from there sent to Alexandria, where he was admitted, on June 14th, to Mansion House Hos- pital, whence he was tiansferred, on the 16th, to hospital at Concord, New Hampshire. Paralysis of both lower extremities ensued, and the patient suffered from constant uneasiness and pain in the head. He was examined by Surgeon J. W. Buckman, 5th New Hampshire, ani discharged from the service on the 12th of August, 1863. His name does not appear on the Pen- sion List. Miles, Levi, Private, Co. C, 52d Indiana Volunteers, aged 50 years, was wounded at Fort De Russy, Louisiana, March 14th, 1864, by a conoidal ball, which entered through the lobule of the left ear, and emerged at the nape of the neck, below the occipital bone, contusing in its course, but not fracturing, the temporal bone. He was sent, on March 16th, to the hospital steamer Woodford, and, on April 30th, was transferred to the hospital steamer R. C. W’ood. On May 8th, he was sent to New Orleans, and thence to the Overton Hospital at Memphis, Tennessee. He was returned to duty on September 5th, 1864. On February 13th, 1835, he was admitted to the Washington Hospital at Memphis, suffering from frequent attacks of trembling, and other symptoms of paralysis. The wound had not yet healed. He was discharged from service on April 20th, 1865. Pope, Theodore, Piivate, Co. C, 9th Ohio Volunteers, received, at the battle of Chickamauga, Georgia, September 19th, 1833, a gunshot contused wound of scalp. He was admitted into Hospital No. 1, Nashville, Tennessee, on September 25th, and, on September 27th, was sent to Louisville, and admitted into Hospital No. 4, where his wound was found to be complicated by contusion of tbe left parietal bone. On December 30th, 1863, he entered Washington Park Hospital, Cincinnati, and, on Jan- uary 8th, 1834, was sent to Camp Dennison, where he was discharged from service by reason of partial hemiplegia of the right side of the body. His name does not appear on the list of pensioners. The case is reported by Surgeon William Varian, U. S. V. Remick, Martin, Private, Co. I, 79th Illinois Volunteers, aged 19 years, was wounded, at the battle of Murfreesboro’, Tennessee, December 31st, 1832, by a round musket ball, which struck about the junction of the occipital and parietal bones, and passed laterally through the integument, making a furrow nearly three inches in length, and touching and bruising, without frac- turing, the bone. He was, on January 25th, 1833, admitted to Hospital No. 5, Murfreesboro’; on February 16th, he was sent to Hospital No. 8, Nashville; on March 1st, to Hbspital No. 13, Louisville, Kentucky; and, on ISIarch 8th, to the hospital at Quincy, Illinois. He suffered occasionally from tremors, more or less paroxysmal, but in February, 1864, the wound had healed. He still complained of pain in the head, and was subject to many nervous symptoms. He was discharged from the service ou May 18th, 1835. He is not an applicant for a pension. Snyder, Joseph, Colonel, 7th West Virginia Volunteers, received, at the battle of Fredericksburg, Virginia, December I3th, 1862, a severe gunshot contusion of the skull. The bone was denuded of periosteum, and slight paralysis of the left arm supervened. The patient was treated in private qu.arters, was furloughed on December 18th, 1862, and finally discharged from the service on September 7th, 1833. His name does not appear on the Pension List. Stanley, J. D., Private, Caskie’s Virginia Battery, was admitted into Confederate Hospital No. 1, Richmond, Virginia, with a gunshot wound of the scalp, with contusion of the cranium, received on September 24tli, 1833. Hemiplegia resulted from the injury, and the patient was furloughed for sixty d.ays on November 24th, 1833. GUNSHOT CONTUSIONS OF THE CHANIAL BONES. 115 Sterling, William, Private, Co. B, 44fli Illinois Volunteers, aged 32 years, was wounded, at the battle of Kenesaw Mountain, Georgia, June 27th, 1864, by a fragment of shell, which struck the right suiiraorbital ridge, injuring the frontal bone and destroying the right eye. He had previously received, at the battle of Cliickamauga, Tennessee, September 19th, 1863, a flesh wound of the right arm. He was, on November 29th, 1864, admitted to the hospital steamer E. C. Wood, and, on December 1st, transferred to the hospital at Mound City, Illinois. Chronic neuralgia of the right supraorbital nerve followed. The patient was discharged from the service on February ICth, 1865. The strength and usefulness of the right arm were impaired. His name does not appear on the Pension Eolls. Sherid.\N, Thom.vs, Pi-ivate, Co. B, 3d United States Cavalry, aged 27 years, was wounded, near Little Eock, Arkansas, October 16th, 1884, in the head by a conoidal ball, which lodged beneath the scalp, near the right ear. He was admitted, on October 23d, to the hospital at Little Eock. Convulsions supervened, and death occurred on December 23d, 1864. Thompson, Kuxd, Private, Co. I, 82d Illinois Volunteers, aged 30 years, received, at the battle of Chancellorsville, Virginia, May 3d, 1863, a wound by a pistol ball, which struck the head and denuded the left parietal of periosteum. He was admitted to the field hospital of the 3d division of the Eleventh Corps on May 4th, 1863, and transferred to Douglas Hospital at Washington on July 21st. During the progi’ess of the case, paraplegia ensued. Tiie patient also suffered from a general and constant pain in the head. He Mas transferred to Christian Street Hospital at Philadelphia on September 15th, 1863. Acting Assistant Surgeon W. W. Keen, jr., reports that, on the date of his dischai’ge, although sufi'ering from an evident disease of the brain, he had so far improved as to be able to walk. Discharged February 17th, 1864. His name does not appear on the Pension Eolls. Wagoner, Jeremiah, Private, Co. G, 85th Illinois Volunteers, aged 25 years, was wounded, in an engagement at Peach Tree Creek, Georgia, July 19th, 1864, by a musket ball, which entered at the upper part of the frontal region, and, passing directly backward over the vertex, grazing the bone in its passage, made its exit at a distance of three inches from the point of entrance. He was received, on July 23d, into No. 2 Hospital at Chattanooga, Tennessee, and from there successively transferred to Nashville, Jeffersonville, St. Louis, and Mound City, Illinois. He was admitted to the hospital at the latter place on September 4th, 1864, at which time the wound was discharging freely, but gradually healing. There was also paralysis of the right arm, which the patient stated had began on receipt of injury, and gradually increased until the limb had become useless. He was transferred on September 23d, and, on the following day, admitted to hospital at Quincy, Illinois, ■where he remained until returned to duty, April 12th, 1865. Jjoss or Impairment of Vision. — Many forms of impairment of vision resulted from gunshot scalp wounds, with contusion of bone and lesions of the nerves, or secondary disorders of the brain. Conjunctivitis, ptosis, amblyopia, and amaurosis were the consecutive eye diseases most commonly observed. The following cases and those of McLarney (p. 100), and Patterson (p. 104), belong to this class : Art, James, Private, Co. E, 2d Pennsylvania Volunteers, aged 19 years, was wounded, in an engagement before Petersburg, Virginia, June 18th, 1864, by a conoidal musket ball, which struck the frontal region one and one-half inches above the left eye, contusing the bone. He was admitted into the field hospital on the 19th, and, a few days later, sent to the Chesapeake Hospital at Fort Monroe. On July 4th, the patient was transferred to Philadelphia, and admitted into the McClellan Hospital. On August 8th, he was sent to Turner’s Lane Hospital. There was ptosis of the eyelids of both eyes, and loss of vision for some days. On May 10th, he was again received jnto the McClellan Hospital, and on July 13th, 1865, was mustered out of service. The case is reported by Surgeon Lewis Taylor, U. S. A. The name of this patient does not appear on the Pension List. Buzzell, Hiram H., Private, Co. G, 40th Massachusetts Volunteers, aged 38 years, received, in an engagement before Petersburg, Virginia, in June, 1864, a contusion of the skull, by a fragment of shell. He was admitted into the hospital of the Eighteenth Army Corps on July 1st. On July 2d, he was transferred to the general hospital at Fort Monroe, Virginia. Conjunctivitis supervened. He was returned to duty, July 29th, 1864. Cole, Jacob, Private, Co. I, 64th Illinois Volunteers, aged 24 years, received, at the battle of Nashville, Tennessee, December 13th, 1864, a gunshot wound of the scalp, with contusion of the bone. He was admitted, on the following day, to hospital No. 1, Nashville, and, on May 3d, 1865, transferred to hospital No. 2, of the same city. For a time he suffered from chronic conjunctivitis, but he recovered and was returned to duty on July 16th, 1865. Emerick, Jacob, Private, Co. A, 148th Pennsylvania Volunteers, aged 23 years, received, at the battle of Chancellorsville, Virginia, May 3d, 1863, a contusion of the right parietal bone, by a fragment of sliell. He was admitted into the field hospital of the 1st division of the Second Corps on the following day, and, about June 13th, was sent to the hospital at Point Lookout, Maryland. On September 29th, he ivas transfen’ed to the Mower Hospital at Philadelphia. Vision was much impaired. On December 22d, 1863, he was returned to duty. Gr.viiaji, Michael, Corporal, Co. H, 103d Ohio Volunteers, aged 23 years, received, during the siege of Knoxville, Tennessee, November 18th, 1863, a gunshot contusion of the right parietal. lie was admitted on the same day to hospital No. 3, Knoxville ; on March 8th, 1864, he was sent to the hospital at Cleveland, Ohio, and, on April 7th, 1864, transferred to the Veteran Eeserve Corps. On July 0th, he was admitted to the Satterlee Hospital, Philadelphia, suffering from granular con- junctivitis. He "(vas discharged from the service on July 6th, 1835, on account of impaired vision, the result of gunshot wound of the head. His name is not upon the Pension Eoll. Hays, E. B., Private, Co. II, 2l8t Mississippi Eegiraent, was admitted into Jackson Hospital, Eichmond, Virginia, with a gunshot wound of left temporal region, received March 25th, 18‘!5. Vision was impaired. 116 WOUNDS AND INJURIES OF THE HEAD, Hagax, Thomas, Captain, Co. G, 71st Pennsylvania Volunteers, received, at tlio battle of Antietam, September 17tb, 18G2, a gunshot wound over left paiietal bone, causing amaurosis of both eyes. He was unable to do duty until November Kith, when be joined his regiment, but was compelled to apply for sick leave again on December 19th, 1802. He resigned on February 7tli, 1833. The loss of vision was almost complete in the left eye, and the right eye Avas only impaired. In April, 1835, Pension Examiner T. F. Smith, of New York, reports that the left iris w;ib very much dilated; that he cmdd not read other than the very largest type. James, W. J., Sergeant, Co. F, 83d Ohio Volunteers, was wounded at the battle of Arkansas Post, Arkansas, January lltb, 1833, by a conoidal musket ball, which struck against the left frontal eminence, and glanced backwards as far as the central portion of the left parietal, denuding the bone to the extent of three inches. The vision became impaired, and was, for a short time, nearly lost. He was taken to the hospital steamer D. A. January, on January 13th, and conveyed to Memphis, Tennessee, where he was admitted, on the 23d of the month, into Hospital No. 3. In the course of two or three days, he was seized with convulsions, which recurred at intervals of three or four weeks. The vision of the right eye was more affected than that of the left, and seemed to vary with the condition of the wound. He was discharged from service on the 4th of April. The wound had healed to some ■extent, and looked healthy. Thus far, no exfoliation of bone had taken place. The patient walked with a feeling of giddiness and insecurity, the cerebral symptoms not being in any degree alleviated, though his general health was good. In July, 1838, James was a pensioner at six dollars per month, his disability being rated at three-fourths. LanIgan, James, Priv.ite, Co. E, 25th Massachusetts Volunteers, received, in an engagement before Petersburg, Virginia, June 23d, 1834, a gunshot contusion of the skull. He was admitted to hospital at Hampton, Virginia, on June 25th, and, on .1 uly 4th, sent to Filbert Street Hospital, Philadelphia. On July 24th, he was transferred to Summit House Hospital; thence, on August 24th, to Satterlee Hospital, M'here, on May 20th, 1835, he was discharged from service, by reason of impaired vision. His name does not appear on the Pension List. The case is reported by Surgeon John E. MacDonald, U. S. V. Moore, J. C., Sergeant, Co. H, 99th Pennsylvania Volunteers, aged 37 years, received, at the battle of the Wilderness, Virginia, May 5th, 1834, a wound of the frontal region by a conoidal musket ball, which scraped the bone. He was admitted into the field hospital of the 3d division. Second Army Corps, and, a few days later, sent to Washington, and admitted, on May 11th, into the Finley Hospital. Simple dressings. The patient was transferred to Philadelphia on May IStli, and was admitted into the South Street Hospital. On May IGth, 1835, he was sent to the Summit House Hospital, and, on .July 5th, 1865, he was discharged from the service. The case is reported by Surgeon St. I. W. Mintzer, U. S. V. He was pensioned July 6th, 1885, and, in May, 1837, Pension E.xaminer T. B. Reed reported that his eyesight was much impaired, and that he suffered fi'om giddiness and headache, and ho thought the pensioner’s disabilities permanent, though some amelioi'ation might be anticipated. Neil, Wm. IL, Captain, Co. D, 26th New Y'ork Volunteers, was wounded at Fredericksburg, Virginia, December 13th, 1832, by a conical ball, which passed across his forehead about an ineb above his eyebrows, making a very slight wound, hardly sufficient to draw blood, but j)robably contusing the os frontis. He was instantly rendered totally blind ; at the same time, the motor nerves near the eye were paralyzed, so that the lids drooped, notwithstanding every effort he made to raise them. The eye-balls were entirely devoid of cx]iression. He was admitted to regimental hospital, and thence sent to general hospital. Surgeon W. B. Coventry, who reports the case, states that he incidentally beamed afterwards that the patient commenced to recover the sight of one eye. This officer’s name does not appear on the roUs of the Pension Bureau. Newson, John G., Sergeant, Co.' B, 30th North Carolina Regiment, aged 18 years, was wounded in an engagement at Kelly’s Ford, Virginia, November 7th, 1833, by a conoidal musket ball, on the back and upper part of the scalp, contusing the skull. He became unconscious, and remained so until the next day. On November 9th, he was admitted to the Douglas Hospital, Washington, D. C. He was weak and giddy, his eyes were red and injected, and very sensitive to light. He had no appetite, felt stupid, and had constant inclination to vomiting. These symptoms continued for some days, but, on November 23d, he was free from pain and able to walk about. His appetite had improved, and the discharge from the wound looked healthy. He was transferred to the Lincoln Hospital, and, on December 7th, 1863, sent to the Old Capitol Prison. The case is reiiorted by Acting Assistant Surgeon Carlos Carvallo. Ploti', Litwis, Sergeant, Co. A, 71st Ohio Volunteers, .aged 25 years, was wounded in an engagement in front of Nashville, Tennessee, December 15th, 1834, by a conoidal musket ball, which contused the frontal bone, and destroyed the vision of the right eye. He was admitted, on the 17th, into Hospit.al No. 1, Nashville, .and, on the 22d, transferred to Hospital No. 15, of the same city. On the 4th of January, 1865, he was sent to the Brown Hospital at Louisville, Kentucky, and, in March, transferred to Camp Dennison, Ohio. Simple dressings constituted the main treatment. He recovered, and was discharged from service on the 13th of June, 1835. The Commissioner of Pensions reports, December 11th, 1839, th.at Plott is a pensioner at four dollars |)er month. The sight of the right eye is destroyed, and the hearing impaired as well. Souder, Axdrew, Private, Co. C, 3d Michigan Volunteers, aged 30 years, in the action at GroVeton, Virginia, August 27th, 1832, received a gunshot contusion of the left temporal region. He was admitted into the Georgetown College Hospital, D. C., on December 13th, and, on .January 2d, was transferred to Philadelphia, and admitted into the Mower Hospital. Loss of vision of the left eye resulted. He was discharged from service, February 21st, 1833, and pensioned. The wound caused arthritis of the temporo-maxillary articulation, ending in partial .anchylosis, so that, according to the report of Pension Examining Surgeon Wilson Jewell, the patient was unable to open his mouth more than half an inch. Deafness.— The cases of KiNG'(p. 101), Laughlin (p 109), and of Chamberlain (p. 119), and those detailed in the fourteen following abstracts, are examples of deafness follow- ing gunshot contusions of the skull : iD o Artus, Charles, Private, Co. I, 15th New York Artillery, aged 30 years. Contusion of the left tempor.al by a piece of shell. Weldon Railroad, August 20th, 1834. Treated at held hospital of Fifth-Corps, .and Mount Pleasant, Washington. GUNSHOT CONTUSIONS OF THE CKANIAL BONES. 117 Discliarged from service, June 20tli, 1865, on account of deafness of the left ear and facial neuralgia, by Assistant Surgeon II. Allen, U. S. A. His name docs not appear on the Pension List. Bexson, Stephex D., Sergeant, Co. A, 31st Maine Volunteers, aged 20 years, was wounded at the battle of Spottsyl- vania Court House, Virginia, May 12th, 1864, by a conoidal ball, which entered the left side of the head, one inch behind the meatus auditorious externus, on a line with its opening, and emerged close to the acromion process of the right scajiula. He was entirely unconscious for several hours, but had some realization of pain in the evening, when he made an ineffectual effort to get on his feet. He was admitted to the hospit.al of the 2d division of the Ninth Corps, and, on May 24th, was sent to the Harewood Hospital, Washington. For about three w'eeks there was much mental aberration, especially at night. Aetg. Asst. Surgeon Sumner A. Patten, who reports the case, examined the patient on June 20th, 1864. The wounds of entrance and of exit discharged freely. There was numbness of the left side of the head, and deafness of the left car. The scalj) in the vicinity of the wound was much swollen. On rising to his feet, he was so dizzy that ho was compelled to lay hold of something to avoid falling. Occasionally small pieces of necrosed hone were discharged from the left ear. Sergeant Benson, commissioned as lieutenant, on August 1st, returned to his regiment, but, on December 5th, 1864, resigned. On April 2d, 1853, Doctor I’atten wrote that this officer had not been able to labor since the reception of the injury; that there was a constant feeling (ft' weakness, although his appetite was generally good. Confusion of thought and impairment of memory were also well-marked effects of the injury. His general health was deteriorated, and he weighed but 144 pounds, having weighed 103 when he enlisted. In September, 1868, Examining Surgeon E. F. Sanger reported that this pensioner, residing in Bangor, Maine, had tbtal deafness of the left ear, and that his general health w’as very poor, and his disabilities total. In a previous communication. Pension Examiner J. C. Weston reported that frequent abscesses formed about the mastoid process, due probably to caries. Bevelheimer, George W., Private, Co. A, 19th Indiana Volunteers, was wounded at the second battle of Bull Run, Virginia, August 30th, 1832. The missile entered over the inferior curved line of the occipital bone, two inches to the left of the median line; it then passed forward, immediately below the auditory foramen, and produced a largo lacerated exit wounil in front of the ear. He was admitted on September 0th to Judiciary Square Hospital, at Washington, D. C. At the end of the third week, although his wounds had nearly closed, there tvas an entire loss of hearing on that side, the recovery of which the probabilities were very unfavorable. He was discharged from the service, December 16th, 1802. His name does not apjiear on the Pension List. This case is reported in the Boston Medical and Surgical Journal, volume 07. page 493. Duxgax, T. J., Private, Co. F, 46th Pennsjdvania Volunteers, received, in an engagement at Cedar Mountain, Vhyinia, August 9th, 1832, a gunshot wound of the right tenlple. The bone near the auditory foramen was contused, and the facial nerve was implicated. He was admitted, on August 13th, to the 2d division hospital, at Alexandria, and, on August 31st, transferred to the .Judiciary Square Hospital, Washington, whence he was discharged from the service on November Pith, 1862. The sense of hearing was impaired, and theri ght side of the face paralyzed. In March, 1863, Pension E.xaminer G. McCook, of Pittsburgh, Pennsylvania, reported this man’s disabilities permanent and incurable. In November, 1807, Pension Examiner' E. Swift reported that the sense of hearing on tlie right side was almost entirely lost, and that facial paralysis existed, together with an inability to close the right eyelids. Goodrich, James D., Private, Co. F, 124th Ohio Volunteers, aged 21 years, received, at the battle of Buzzard Roost, Georgia, Ulay 9th, 1834, a contusion of the left parietal by a conoidal musket ball. He w'as treated in a field hospital until Ulay 10th, when he was transferred to Nashville, Tennessee, and remained in Hospital No. 19, until May 19th, when he was sent to Clay Hospital, Louisville, Kentucky, and thence, on June 29th, to Camp Dennison, Ohio, from whence he was discharged from the service, August 27th, 1804, by reason of deafness and impaired mind. His name does not appear on the Pension List. Surgeon W. Varian, U. S. V., reports the case. Gregory, Adam, Corporal, Co. H, 18th Ohio Volunteers. Shell contusion of the skull. Chickamauga, September 19th, 1863. Treated at Cumberland nospit.al, Nashville. Slight deafness resulted. Returned to duty September 28th, 1803. lie does not appear to be a pensioner. Havexs, Charles P., Private, Co. F, 144th New York Volunteers, aged 28 years. Contusion of the left temporal region by a conoidal musket ball. Honey Hill, South Carolina, November 30th, 1834. Treated at regimental, Hilton Head, IiIcDougall, and Elmira Hospitals, and discharged from service May 25th, 1805, and pensioned. In September, 1808, Examining Surgeon John S. Pfouts reports that this man had complete deafness of the left ear. IaROESEX, Cyrus, Private, Co. A, 77th Illinois Volunteers, was wounded at the battle of Arkansas Post, January 11th, 1833, by a round ball, which struck the left side of the head, contusing the frontal bone, passed backwards above the base of the ear, making a track three inches in length beneath the scalp. He was conveyed to Memphis, Tennessee, by the hospital steamer D. A. .January, and admitted, on January 22d, to the Adams Hospital. Audition of the left ear was entirely destroyed ; that of the right ear is perfect. The wound healed without any untoward symptom. He was returned to duty .July 2d, 1803. His name does not appear on the Pension Rolls. Peppers, Martix, Private, Co. D, 3d Iowa Volunteers, was, on November 4th, 1832, admitted to the hos])ital .at Keokuk, Iowa, suffering partial deafness and disease of the frontal sinus, right side, caused by an explosion of a shell in the engagement at Big Hatchie, Tennessee, October 5th, 1832. The injury was followed by abscess of the frontal sinus. The patient was disch.arged from the service on March 30th, 1803. His name does not .appear on the Pension List. Pulliam, Eli.JAH C., Private, Co. H, 32d Illinois Volunteers, received, at the battle of .Shiloh, Tennessee, A|)ril (ith, 1832, a wouijd of the scal[) in the occipital region, with contusion of bone, by a buckshot. His hospital history iirevious to Aug«st 0th, the date on which he was admitted to House of liefuge Hospital at >St. Jjouis, Missouri, is w.ai'.’ing. Erysii)elas supervened. The patient suffered several relapses of the disease, which finally terminated in abscesses behind l)otli ears, causing temporary deafness on tlie left side. He was discharged from tlie service on October 15th, 1832. His name is not recorded on tlie Pension Rolls. 118 WOUNDS AND IN JUDIES OF THE HEAD, Rawdon, James, Corporal, Co. K, 34tli IMassachusetts Volunteers, aged 18 year.s, was wounded, at the battle of New Market, Virginia, May 15tli, 1834, by a fragment of shell, which lacerated the scalp over the posterior border of the left parietal bone to the extent of two inches, and contused the bone. He was conveyed to the hospital at Cumberland, Maryland. The wound healed favorably, but the patient suffered for two months with pain and partial deafness. On October 25th, the headache ceased and the hearing was restored, and, on October 23th, 1834, the man was returned to duty. His name does not appear upon the list of pensionei’s. liisa^ A. JL, Private, Co. I, 11th North Carolina Infantry, received, July 1st, 18G3, a gunshot scalp wound of the temporal region, with contusion of the bone. He was admitted into the Moore Hospital No. 24, Richmond, October 26th. Audition impaired. On November 4th, 1833, he was furloughed for sixty days. Thurston, Willi.am F., Surgeon, 1st Rhode Island Artillery, was wounded, at the battle of Fair Oaks, June 28th, 1832, by a ball from a sphei-ical case shot, which struck his left parietal bone, contusing but not fracturing it. Notwithstanding his injury, he continued to attend the wounded of his regiment till a few days after the battle, when he had a leave of absence for twenty days. Deafness came on gradually, and Surgeon Thurston finally became incapable of performing duty in the field. On April Gth, 1833, he was mustered out of service, and pensioned. In April, 1839, Pension Examining Surgeon C. Hoppiu reported that he was completely deaf, and a great sufferer from vertigo. WiNSOU, W. H., Captain, Co. F, 18th Massachusetts Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1832, a gunshot wound of the head. He was admitted, on the same day, to the field hospital of the 1st division of the Fifth Corps. On December 17th, 1832, he reported to Surgeon Thomas Antisell, at Washington, D. C., who reported the injury as a scalp wound, with contusion of the left temple, with loss of hearing on that side. He was furloughed on December 19th for twenty days. Resigned March 15th, 1833. His name is not found on the Pension Rolls. Aphasia . — This obscure and curious affection was observed in three cases, as a sequence of gunshot contusions of the skull. One instance is cited on p. 105 : Chapman, II. V., Private, Co. A, Gth Virginia Cavalry, aged 29 years, received a wound, by a pistol ball, on October 11th, 1833, above the left superciliary ridge. The wound was contused, and the ball passed out from under the ligaments about the left jaw, after causing a concussion of the brain, resulting in aphasia. He was admitted to the Chimborazo Hospital, Richmond, October 23d, 1883, and was furloughed on the 17th of the following month, his speech being partially regained, though he could not formulate sentences in his mind. Hclrnes, J. C., Private, Co. F, 48th North Carolina Infantry, received a gunshot wound of the scalp, contusing the skull. He was admitted into the No. 8 Hospital, Richmond, on September 28th, 1882. Aphasia resulted. On November 1st he was furloughed. Epilepsy . — Nine cases are reported to have resulted in epilepsy, as a remote effect of gunshot contusions of the cranium : Anderson, Alexander, Private, Co. I, 24th Massachusetts Volunteers, was discharged from the service on October 19th, 1882, .at Camp Convf the cranium near the vertex, tearing the scalp and con- tusing the cranium. There was much mental aberration. The following cases of gunshot wounds of the head, with contusion of the hones of the cranium, terminated fatally : Caraker, J. V., Corporal, Co. D, Pith Alabama Infantry, received a wound of the frontal region, with injinw atient appeared in every way better. The wound was closed, and stimulants were administered, but exhaustion followed, and death occurred on October 11th, 1862. At the autopsy, it was found that the ball had struck the os frontis on the left side, near the sagittal suture, two and a half inches from the middle line of the cranium. 'J'ho inner table was necrosed over an irregular circular si)ace, one and a half inches in diameter, the dij)lo(! between the outer and- inner tallies at Fig. 41. — Calvaria trephined in the left frontal region for gunshot contusion. Spec. 1199, Sect. I, A. M. M. 124 WOUNDS AND INJURIES OF THE HEAD, this point l)eing carious. There was an abscess, with greenisli indurated walls, three inches in diameter, in the anterior lobe of the left cerebral hemisphere. It had opened, and its contents had filled the cavities of the brain. There was no pus under the diseased bone upon the surface of the brain, nor did there seem to be any immediate communication between the diseased bone and the abscess. The pathological specimen is figured in the foregoing wood-cut, (Fig. 41.) It shows the vault of the cranium, with the disk in place. The internal table is cribriform. The outer taWe is poroas, and discolored to a slight degree. The specimen and history were contributed by Acting Assistant Surgeon G. E. Morehouse. Attig, IVilgiaji, Private, Co. A, 49th Pennsylvania Volunteers, aged 25 years, was wounded near Eappahannock Station, Virginia, November 7th, 1863, by a conoidal musket ball which struck the forehead near the left frontal eminence, denuding the bone of its periosteum for about one inch. He was conveyed to Washington, and admitted into Harewood Hospital on the 9th, complaining of slight headache over the region of the eyes. His pulse was normal, and his appetite poor. On the 17th, chills, with vomiting, supervened, and the eyes became lachrymose. These symptoms continued until the 19th, when he was anaesthetized, and Surgeon E. B. Bontecou, U. S. V., made a crucial incision through the scalp, when pus was found issuing through the denuded bone. The trephine was then applied near the left fi-ontal eminence, giving exit to a small quantity of pus, which was found between the dura mater and the skull. After the operation the patient became free from pain. During the night of the 20th, he became delirious, and lay in a stupor nearly all the time, but answered questions correctly. The next morning the fore- head and right eye-lids were oedematous, and the pulse was 75, and feeble. On the 23d, low muttering delirium followed, coma ensued, the alvine evacuations became involuntary, and his breathing stertorous. At eleven o’clock A. M. of the 24th, the Fio. 42. — Perforation of the left os frontis for .1 pfiinshot confusion, followed by symptoms of compression. Spec. 2024, Sect. I, A. M. JI. dura mater was incised, giving exit to a small quantity of pus, but no relief was afforded, and death occurred two hours subsequently. The pathological specimen was sent to the Army Medical Museum, and is represented in the wood-cut (Fig. 42). It was forwarded, with its history, by Surgeon E. B. Bontecou, U. S. V. B.vker, Charles K., Private, Co. D, 27th lilassachusetts Volunteers, aged 25 years, was wounded at the battle of New Berne, North Carolina, Jlarch 14th, 1862, by a conoidal musket ball which made a long furrowed wound of the right parietal region, lacerating the scalp, and denuding the pericranium. He was treated at a field hospital by his regimental surgeon. The right side of the scalp was shaven, and a compress, dipped in cold water, was secured over the wound by a bandage. The patient was required to keep his bed in the log hut used as an hospital, and to observe a strict diet. He had no headache, nor any symptom of disturbance of the brain. Careful exploration revealed no injury of the bone. On March 20th, the wound of the scalp was fixirly cicatrizing, and the patient was sent on an hospital transport, up the Neuse river, to the Craven Street Hospital at New Berne, five miles distant. Two days subsequently, through the inadvertence of an hospital steward, this man’s name was included in the list of wyimded to be sent northward on the hospital transport steamer New York. Surgeon .1. B. Upham, in charge of the transport, reports that he had no ceiebral symptoms on the passage. He proceeded to his home in Amherst, Massachusetts. On April 3d, he complained of headache, and the following day sjuiiptoms of compression of the brain were manifested. On April 7th, he was trephined by two of the local practitioners, and died a few hours after the operation. Assistant Surgeon D. B. N. Fish, 27th Massachusetts Voluntoeu-s, a resident of Amherst, writes, in 1833, that the two surgeons who performed the operation had died and loft no notes of the case; but thinks it certain, from the report of one of the witnesses of the operation, that a clot of blood was found underneath the cranium, at the point of impact. Chapman, S. D., Private, Co. H, 92d Ohio Volunteers, received, at the battle of Chickamauga, September 23d, 1863, a gunshot wound of the scalp, near the upper posterior angle of the right parietal, with a contusion of the bone. He was sent to Nashville, and admitted to Cumberland Hospital on the 25th. The wound produced little inconvenience until October 4th, when grave head symptoms, such as delirium and convulsions, supervened. There was hemiplegia also. On October 5th, the patient was in a comatose condition, and trephining was resorted to. When the skull was perforated, exit was given to a quantity of pus, which had formed between the dura mater and cranium. Consciousness was restored almost immediately, and apparent steady improvement for the next twenty-four hours ; but symptoms of compression then recurred, and the patient died on October 9th, 1863. At the autopsy, the right hemisphere was found partially disorganized, and covered with a layer of pus, which extended to the longitudinal fissure. The operator. Surgeon C. McDermont, U. S. V., reported the case. Chap.pel, Beniamin F., Sergeant, Co. II, 8th New York Cavalry, aged 27 years, was wounded, before Petersburg, Virginia, April 1st, 1865, by a pistol b.all which entered one inch above and one and a half inches to the left of the occipital protuberance and emerged just below it on the opposite side, denuding the bone of pericranium. He was admitted to the hospital of the 3d division. Cavalry Corps, and on the 3d, was sent to Washington, where he entered Harewood Hospital on the 5th. Until the 14th, the patient seemed to, bo improving, hut on that day a slight haemorrhage from the occipital artery occurred, causing the loss of about six ounces of arterial blood. The haemorrhage was arrested by means of eompression, and the case apparently progressed rapidly. On the evening of the 18th, the patient, however, complained of considerable pain in the region of the cerebellum. On the following day considerable gastric irritation manifested itself, and, at intervals, there was slight delirium. Ether was administered, and Surgeon E. B. Bontecou, U. S. V., made an incision two and a half inches in length, just below and parallel to the lambdoidal suture, retracted the scalp, applied the trephine, and removed a disk of bone, giving exit to a (]nantity of ])us. The patient reacted promptly, after the operation, and sated at corps and Washington hospitals. Returned to duty. Not on Pension List. Case. — Private Benjamin .Jerrough, Co. G, 2d Vermont Volunteers, aged 34 years. Cold Harbor, Juno 3d, 1864. Conoidal musket ball. Treated at Lincoln and York hospitals. Returned to duty July 27th, 1864. Not on Pension List. Case. — Sergeant James Kay, Co. C, 83d Indiana Volunteers. Gunshot fracture of outer table of the vault of the cranium. Jonesboro’, Georgia, August 30th, 1864. Treated at field hospital, where he dicid on August 31st, 1864. Case.— Privmte James McCarty, Co. F, 105th Pennsylvania Volunteers, aged 37 years. -Petersburg, Virginia, April 2d, 1865. Fragment of shell. Treated at corps and Carver hospit.als. Mustered out of service .Tidy lllh, 1865. Not on Pen.sion List. 18 138 WOUNDS AND INJUEIES OF THE HEAD, Case. — Sergeant Daniel McDougall, Co. E, 17th New York Volunteers, aged 26 years. Jonesboro’, Georgia, September 1st, 1834. Fragment of shell. Treated at corps, Atlanta, and Nashville hospitals. Eeturned to duty November 29th, 1864. Not on Pension List. Case. — Captain David McGauhey, 5th Pennsylvania Eeserves. Spottsylvania, May 9th, 1864. Treated at corps and Officers’ hospitals, Washington. Mustered out of service July 13th, 1864. Not on Pension List. Case. — Private Thomas Maley, Co. F, 7th Missouri Volunteers, Vicksburg, Mississippi, May 12th, 1863. Conoidal musket ball. Treated at field and Lawson hospitals. Ti-ansferred to the Veteran Eeserve Corps December 10th, 1863. Not on Pension List. Case.- — Private E. F. Maples, Co. G, 12th Alabama Eegiment, aged 21 years. Winchester, Virginia, September 19th, 1864. Conoidal musket ball. Treated at Winchester, West’s Building, and Point Lookout hospitals. Sent to Provost Marshal for exchange February 11th, 1865. Case. — Corporal David Phillips, Co. D, 149th Pennsylvania Volunteers, aged 20 years. Spottsylvania, Virginia, May 8th, 1884. Conoidal musket ball. Treated at Douglas and Pittsburgh hospitals. Eeturned to duty September 23d, 1864. Not on Pension List. Case. — Adjutant John S. Eiehl, 26th Pennsylvania Volunteers, aged,34 years. Mine Eun, Virginia, November 27th, 1833. Fragment of shell. Treated at Wolfe street, Alexandria, and Officers’, Philadelphia, hospitals. Eeturned to duty March 4th, 1864. Not on Pension List. Case. — Sergeant George Eoll, Co. A, 122d Ohio Volunteers, aged 25 years. Petersburg, Virginia, March 25th, 1865. Conoidal musket ball. Treated at corps, Lincoln, and Satterlee hospitals. Mustered out of service May 31st, 1865. Not on Pension List. Case. — Private Charles W. Eutherford, Co. B, 60th Illinois Volunteers, aged 25 years. Jonesboro’, Georgia, September 1st, 1864. Grape shot. Treated at corps, Nashville, and Louisville hospitals. Eeturned to duty December 27th, 1864. Not a pensioner. Case. — Private Henry Sheets, Co. H, 13th Pennsylvania Cavalry, aged 20 years. Deep Bottom, Virginia, August 13th, 1834. Conoidal musket ball. Treated at corps, Emory, and South street hospitals. Discharged from service May 20th, 1865. Pensioned at four dollars per month. Case. — Corporal G. B. Smith, Co. B, 2d United States Sharp-shooters, aged 32 years. Spottsylvania, Virginia, May 16th, 1884. Conoidal musket ball. Treated at Carver and Mower hospitals. Transferred to Veteran Eeserve corps January 24th, 1865. Pensioned at eight dollars per month. Sixteen alleged fractures of the outer table were of the occipital region, eleven of the patients were Union and five were Confederate soldiers, of whom five returned to duty, five were discharged, and three died. One was exchanged, one furloughed, and in one case the ultimate result is not reported. The nature of the projectile is reported in eleven cases: musket balls in seven, pistol ball in one, and shell fragments in three : Case. — Private S. A. Cai-lin, Co. A, 70th New York Volunteers. Gettysburg, July 3d, 1863. Treated at corps and Seminary hospitals. Died July 21st, 1863. Case. — Corporal David A. Chandler, Co. B, 126th Ohio Volunteers, aged 22 years. Spottsylvania, Virginia, May 12th, 1864. Conoidal musket ball. Treated at corps, Emory, Summit House, Satterlee, Camp Chase, and Tripler hospitals. Transferred to Veteran Eeserve Corps March 15th, 1865. Not on Pension List. Case. — Private Henry C. Cross, Co. G, 24th New York Volunteers, aged 18 years, was wounded, at the second battle of Bull Eun, August 29th, 1862, by a fragment of shell which fractured the external table over the occipital protuberance. The wound in the scalp was nearly two inches long. He was conveyed to Washington, and on September 1st was admitted into the Unitarian Church hospital. Slight paralysis of the left arm and leg existed, and the wound was painful. Cold water dressings were applied, an ounce of sulphate of magnesia was administered and a restricted diet ordered. The patient was more or less delirious for two days. On September 30th he had so far recovered as to be able to walk about the ward, and the wound had nearly healed. He experienced no inconvenience from the injury except on exposure to the sun. The case is reported by Surgeon A. Wynkoop, U. S. V. The patient was discharged October 2d, 1862, and pensioned. Pension Examining Surgeon C. E. Clark reports, on February 3d, 1833, that this was a “fracture of the skull, carrying away a portion of its substance.” The wound was nearly healed, and the patient suffered from throbbing pain and giddiness on active exertion. His disability was rated as total, but probably temporary. Case. — Private Eiley A. Davidson, Co. F, 1st Vermont Volunteers, aged 30 years. Cedar Creek, Virginia, October 19th, 1864. Conoidal musket ball. Treated at corps, Satterlee, and Brattleboro’ hospitals. Eeturned to duty December 13th, 1834. Not on Pension List. Case. — Private C. F. Dervey, Co. H, 1st New Jersey Cavalry, aged 24 years. Amelia Springs, Virginia, April 5th, 1865. Pistol ball. Treated at field, Annapolis, West’s Building, and York hospitals. Mustered out of service June 19th, 1865. Not on Pension List. GUNSHOT FEACTUIIES OF THE OUTER TABLE OF THE SKULL. 139 Cask.— Sergeant Alexander Hayes, Co. I, 84tli Indiana Volunteers, aged 32 years. Knoxville, Tennessee, December 17tli, 1834. Colloidal musket ball. Treated at Nashville, Jeffersonville, and Indianapolis hospitals. Discharged from service May 13th, 1865. Not on Pension List. Cask. — Private Joseph Maries, 14th North Carolina Regiment, aged 40 years. Fort Fisher, North Carolina, January 7th, 1865. Treated at Point Lookout hospital. Died April 5th, 1865. Case. — Private John C. Martin, Co. E, 3d New Jersey Volunteers, received, at the battle of Gettysburg, July 3d, 18G3, a gunshot fracture of the outer table of the occipital bone. He was treated at regimental, corps, and general hospitals, and was discharged from service on June 23d, 1864, and pensioned at four dollars per month. Pensioner Examiner F. F. Burmeister reports, March 2d, 1866, that this pensioner suffers fi-om constant pain, and partial loss of memory, and rates his disability at one-half and permanent. Case. — Private W. H. Parmar, Co. A, 23d Ohio Volunteers, aged 43 years. Cedar Creek, Virginia, October 13th, 1864. Fragment of shell. Treated at Sheridan and Cumberland hospitals. Returned to duty November 28th, 1864. Not on Pension List. Case. — Private W. A. Potts, Co. K, 53d Georgia Regiment. Gunshot fracture of outer table of occipital. Treated at Howard Grove Hospital, Richmond. Transferred to Macon, June 4th, 1864. Case.— Private George Prior, Co. K, 83d United States Colored Troops, aged 29 years. February, 1865. Conoidal musket ball. Treated at St. John’s Hospital, Little Rock, Arkansas. Returned to duty September 26th, 1865. Not on Pension List. Case. — Private George W. Reed, Co. H, 12th Ohio Volunteers, was wounded near Laurel Creek, West Virginia, November 12th, 1861. One ball passed through the scalp at the back of the head and lodged in the diploic structure of the occipital, not perforating the bone ; another struck on the outside of the left foot, about an inch below the external malleolus, passed forward and made its exit about two inches from point of entrance. He was admitted to the hospital at Gauley, West Virginia, and was doing well when seen by Surgeon G. G. Shumard, U. S. V., who reports the case. Reed was discharged from the service on December 28th, 1862. His name is not upon the Pension Rolls. Case. — Sergeant H. C. Rinalder, Co. K, 5th Alabama Regiment, aged 26 years. Cedar Creek, Virginia, October 19th, 1864. Conoidal musket ball. Treated at West’s Building and Point Lookout hospitals. Sent to Provost Marshal for exchange April 8th, 1865. Case. — Private J. W. B. Eobinson, Co. G, 1st Virginia Cavalry. Spottsylvania, May 7th, 1864. Fragment of shell. Treated at hospital at Farmville, Virginia. Furloughed August 9th, 1864. Case. — Private David Simpson, Co. A, 1st North Carolina Volunteers, aged 35 years. Olustee, Florida, February 20th, 1864. Conoidal musket ball. Treated at Beaufort hospital. Returned to duty March 24th, 1864. Not on Pension List. Case. — Private A. Young, Co. C, 31st Virginia Regiment. Gunshot fracture of external table of the occipital. Treated at hospital at Farmville, Virginia. Died June 13th, 1864. Twenty alleged cases of fracture of the external table of the skull are reported, without defining the location of the injury, as follows : Case. — Corporal W. T. Bird, Co. B, 11th Alabama Regiment. Gunshot fracture of external table of the skull. Treated at Howard Grove Hospital, Richmond. F'urloughed May 13th, 1864. Case. — Private Napoleon Bombard, Co. K, 11th Vermont Volunteers, aged 21 years. Cedar Creek, Virginia, October 19th, 1864. Fragment of shell. Treated at corps, Filbert street, and Baxter hospitals. Returned to duty January 6th, 1865. Not on Pension List. Case.— Lieutenant Charles H. Briggs, Co. A, 1st Connecticut Cavalry. Hanover Court-house, Virginia, June 1st, 1864. Treated at corps and Officers’ hospitals. Discharged January 20th, 1865. Not on Pension List. Case. — Corporal A. P. Cook, Co. H, 37th Massachusetts Volunteers, aged 22 years. Cold Harbor, Virginia, June 3d, 1864. Conoidal musket ball. Treated at corps, Alexandria, and Satterlee hospitals. Returned to duty September 17tli, 1864. Not on Pension List. Case.— Private Hugh H. Cormack, Co. H, 27th Iowa Volunteers, aged 18 years. Nashville, Tennessee, December Kith, 1864. Conoidal musket ball. Treated at Cumberland and Jeffersonville hospitals, and returned to duty February 25th, 1865. His name does not appear on the list of pensioners. Case. — Lieutenant 7?. F. Felder, Co. I, 25th South Carolina Cavalry. Gunshot fracture of outer table of tlie skull, Juno 18th, 1864. Treated at No. 4 Hospital, Richmond. Furloughed July 14th, 1864. Ca.se. — Private Theodore Kestler, Co. F, 17th Ohio Voluntci'r.s, aged 18 years. Chickamauga, Georgia, September 20tli, 1863. Conoidal musket ball. Treated at corps, Stevenson, and Nashville hospitals. Returned to duty February 5th, 1864. Not on Pension List. Case. — Priv.ate A. B. McLain, Co. M, 12th South Carolina Regiment. Gunshot fracture of outer table of the skull. Treated at Jackson Ilo.^pital, Richmond. Furloughed September 21th, 1864. Case. — Private Charles V. klai-slj, Co. C, Ibih Massachusetts Volunteers, aged 28 years. Gettysburg, .July 3d, 1863. Treated at Corps and Mower hosjiitals. Returned to diilv December 22d, 186'’. Ills name is not upon the Pension List. 140 WOUNDS AND INJUEIES OF THE HEAD, Case. — Sergeant Allen F. Miller, Co. G, 34th Ohio Volunteers, aged 22 years. Winchester, Virginia, September 19th, 1864. Conoidal musket ball. Treated at division, Sandy Hook, and Satterlee hospitals. Eeturued to duty December 2d, 1864. Not on Pension List. Case. — Sergeant Milton Nash, Co. F, 130th Indiana Volunteers, aged 24 years. Atlanta, Georgia, August 6th, 1864. Conoidal musket ball. Treated at field, Knoville, and Louisville hospitals. Discharged from service May 15th, 1865. Not a pensioner. Case.— Private Louis Nelty, Co. D, 149th New York Volunteers, was wounded, at the battle of Gettysburg, Penn- sylvania, July 3d, 1863. He was admitted to a field hospital, where the injury was treated as a scalp wound. On July 16th, he was transferred to the Carver Hospital, Washington, where it was diagnosticated that the outer table of the cranium was fractured. He was returned to duty on October 19th, 1863. His name is not upon the Pension Eolls. Case. — Private Leon Eheims, 3d New York Artillery. Lee’s Mill, Virginia, April 16th, 1862. Treated at Christian street and Fifth street hospitals, Philadelphia. Eetui-ned to duty August 8th, 1862. Not a pensioner. Case. — Corporal Lloyd Seville, Co. F, 1st New Jersey Volunteers. September 14th, 1862. Treated at Judiciary Square Hospital, Washington. Discharged from service December 13th, 1862. His name does not appear on the Pension Eolls. Case.— Private B. J. Smoot, Co. G, 4th North Carolina Eegiment. Gunshot fracture of outer table of the skull. Treated at Chimborazo Hospital, Eichmond. Transferred to Salisbury, North Carolina, June '6th, 1864. Case. — Private F. M. Stricklin, Co. F, 33d Alabama Eegiment. Dallas, Georgia, May 27th, 1864. Gunshot fracture of outer table of the skull. Treated at hospital at Dalton. Furloughed May 30th, 1864. Case. — Corporal F. L. Tarleton, Co. I, 10th Alabama Eegiment. Gunshot fracture of outer table of the skull. Treated at Howard Grove Hospital, Eichmond. Fuiloughed May 24th, 1864. Case. — Private Moses Tonier, Co. K, 47th New York Volunteers, aged 32 years. Petersburg, Virginia, July 24th, 1864. Conoidal musket ball. Treated at corps. Fort Monroe,' and Whitehall hospitals. Discharged from service February 20th, 1865. Not a pensioner. Case. — Private John Toi’borg, Co. K, Purnell’s Legion. Cold Harbor, Virginia, June 3d, 1864. Treated at corps, Alexandria, and Satterlee hospitals. Mustei'ed out of service October 27th, 1864. Not on Pension List. Case. — Private S. E. Wood,, Co. F, 21st Virginia Eegiment. Winchester, Virginia, September 19th, 1864. Conoidal musket ball. Treated at field and West’s Building hospitals. Transferred for exchange October 17th, 1864. Of these patients, thirteen were Union and seven Confederate soldiers. Seven went to duty, five were discharged, and six were furloughed. One was exchanged, and one is unaccounted for. None were pensioned. The nature of the missile is referred to in eight of the cases only, being a shell fragment in one, and conoidal musket balls in seven cases. Of the whole number of one hundred and thirty-eight cases of alleged gunshot fracture of the external table only of the skull, one hundred and eleven appear in the Union, and twenty-seven in the Confederate, reports. There were twelve deaths, two of which were not due to the injuries, but to intercurrent diseases. Of the Union men forty-five were discharged, fifty-six went to duty, three recovered and deserted, and seven died. The names of twenty-six of the Union men who recovered are found on the Pension Eolls. Those wounded in the supra-orbital region frequently suffered from impairment of the senses of vision or of smell, and those struck in the mastoid region, from injury or destruction of the sense of hearing. One suffered from numbness of the lower extremities, another from con- vulsions, and several from vertigo and dizziness. Of the twenty-seven Confederates, three died, six recovered and were exchanged, and eighteen were “furloughed” from hospitals within their own lines, and it is only known of their ulterior history that two of them were “ retired ” by medical boards. I have presented brief memoranda of the one hundred and thirty-eight alleged examples of gunshot fracture of the external table of the skull, in deference to the experienced surgeons who have reported such accidents ; but after a careful examination of the histories of the individual cases, and weighing the evidence impartially, I am sure, I am disinclined to admit that the outer table of the skull is ever fractured in the adult without injury to the inner table, either by projectiles of war or any other external violence, except in the rare instances, enumerated at the beginning of this subsection, of blows or the impact of missiles upon the superciliary ridge, or mastoid or zygomatic processes, and possibly. GUNSHOT FRACTURES OF THE INNER TABLE OF THE SKULL. 141 the occipital protuberance, or by grooving by a sharp shell fragment. Pott, Sir Astley Cooper, Sir Benjamin Broclie, Williamson, and others, refer to indentations of the skull or fractures of the outer table as not uncommon ; but I believe the view entertained by Velpeau and Samuel Cooper, which I have endeavored to illustrate and corroborate, to be the sound one. The reader who would examine further this interesting subject may consult the authorities referred to in the foot note.* Gunshot Fractures of the Inner Table of the Skull. — The returns furnish twenty examples of fractures of the vitreous table of the skull without fracture or depression of the outer table. In ten of these cases, the pathological specimens were preserved and forwarded to the Army Medical Museum. Of the ten cases in which the specimens are wanting, one was observed by Surgeon John Shrady, 2d Tennessee Volunteers, who pub- lished an account of it at the time.j* A more minute history has been found in the case- book of the hospital in which the patient was treated : Case 1. — Private; Matthias A. Tapyer, Co. I, 97th Ohio Volunteers, at the battle of' Murfreesboro’, Tenn., January 3cl, 1833, received a slight scalp wound, from a glancing musket ball, near the antero-superior angle of the left pailetal. He made light of his injury, which caused little pain ; but was sent to Nashville on the 5th, and was admitted into Hospital No. 19. Examination with the probe failed to detect any injury of the skull. Simple dressings were ordered and the patient was allowed the liberty of the ward. For the next few d.ays ho was restless and irritable, and kept getting in and out of bed; but these sjunptoms were not regarded as significant, as the patient gave rational answers when interrogated. On the 10th, the ward-master reported that the patient was exceedingly restless at night, and he thought, at times, delirious, at all events “ very strange in his actions.” The attending surgeon found “nothing abnormal, except a white tongue and accelerated pulse and a puffy appearance of the scalp wound.” As the patient still replied intelligently to questions, these phenomena appear to have excited little solicitude, and no active treatment was instituted. On the 15th there was great gastric irritability, tlie blandest liquids being rejected and the bowels were obstinately constipated. The jiatient Lay in a state of stupor, the flexors of the upper extremities strongly contracted, with occasional subsultus; the pupils dilated and irresponsive to light. He was ordered five grains of iodide of potassium thrice daily, and an ounce of castor oil with a drop of croton oil immediately. It is not mentioned whether these medicines were retained or not, or whether enemata were given. But on the 16th, there was no amelioi'ation of the symptoms, and the eathartic was ineffectually repeated. On January 21st the nurse reported tliat the patient had “ not had a movement from his bowels since his admission.” At this date “all of the symptoms were aggravated;” the patient was, however, still sufficiently conscious to endeavor to protrude his tongue when asked to do so, and to manifest his aversion to “a more thorough examination of the wound.” The propriety of trephining was considered, but it was thought that the pi'o.ximity of the longitudinal sinus to the seat of injury forbade this expedient. A crucial incision of the scalp was made across the wound, and about two drachms of pus escaped. The bone was found to be denuded over a space of the size of a dime. The patient died on the following day, January 22d, 1833. At the autopsy, when the calvarium was removed, a fissure of the inner table was discovered an eighth of an inch to the left of the sagittal suture, with slightly depressed sharp and jagged edges. For a space of two square inches about this fissure the dura mater had undergone structural alteration. Underneath the dura mater was an abundance of thick greenish pus. The brain substance beneath the diseased membrane was softened and friable. The cerebral veins were turgid. The next case appears on the report, for the third quarter of 1864, of the general hospital at Grafton, West Virginia: Case 2. — Private Elijah Bennett, Co. A, llGth Ohio Volunteers, aged 39 years, was wounded at the engagement at Piedmont, Virginia, June 5th, 1834, by a conoidal musket ball which grazed the top of the head, tearing up the scalp. He was treated in a field hospital until the 19th, and then transported to the genei'al hospital at Grafton and placed under the care of Surgeon Socrates N. Shennan, U. S. Vols. He was then laboring under symptoms of subacute meningitis, with comi)ression of the brain. He died three days after admission, June 22d, 1834. At the post mortem examination, a depressed fracture of the inner tables of both parietals was discovered, the fissures crossing about the middle of the sagittal suture. Beneath the dei)r('ssed portion of bone the dura mater was extensively diseased, and a large abscess had formed. *POTT, Observations on the Nature and Consequences of Wounds and Contusions of the Head, Londim, 17G0, p. I.";. Sir Asti.ey Cooi’Ei:, Lectures, London, Vol. I, p. 302. SAUCEllOTnc. Hemoire de V Academic de Chirurgie, T. IV, cd. 1819, p. 322. IlKXNEX, Miliiarg Surgerg, 2d cd., p. 323. Sir BEXJAMIN C. BEODIe, Works collected and arranged hg Mr. Charles Hawkins, London, 1805, Vol. Ill, p. 25. VELPEAU, De V Operation du Trepan dansles plaies de Tele, Paris, 1634, p. 27. Medico-Chirurgical Transactions, Vol. XVI, p. 331. WILLIAMSON, Militarg Surgerg, London, 1863, p. 28. M.VCLEOD, Notes, etc., (already cited,) p. 177. Maitiiew, Med. and Surg. Hist, of Jlritish Armg in- the Crimea, (Oji. cit.,) Vol. II, p. 28. Guthrie, Commentaries. Chisolm, Manual, etc., (Op. cit.,) p. 2.12. Teevan, Experimental Inquiries into certain Wounds of the Skull, in Drilish and Foreign Medico-Chirurgical Review, Vol. XXXIV, p. 205. Miller, A Sgstem of .Surgerg, Edinburgh, 1864, p. 028. PlRlilE, The Hrinciplcs and Practice of Surgerg, London, 1860, p. 273. DEXONVIlliehs et OOSSELIN, Compendium de Chirurgie Pratique, I’aris, 1851, T. II, p. 578. Adams, in Costello's Cgclnpedia of Practical Surgery, Vol. II, p. 476. Lanoutii, Programme, de sinus Frontalis vulncre sinus Terehratione curando, Wittemb. 1748. Schneider, Die Kopfverletzungen, Stuttgart, 1848, p. 6!l. \ American Medical Times, Vol. VI, p. 1 Kl, March 7th, 1863. 142 WOUNDS AND INJUEIES OF THE HEAD A third case is noted in the case-book of Hospital No. 1, Frederick, Maryland, in charge of Assistant Surgeon Eohert P. Weir, U. S. A.: C.YSE 3. — Private Hamilton West, Co. G, 5th West Virginia Volunteers, aged 24 years, at the battle of Opequan, Virginia, September 19th, 1834, was struck on the left side of the back of the head by a musket ball whicli, apparently, inflicted only a scalp wound. After a primary dressing in a field hospital, he was sent to the depot for wounded at Sandy Hook, and thence to Frederick, Maryland, where, on the 24th, he was admitted to Hospital No. 1, under the care of Acting Assistant Surgeon E. W. Mansfield. The wound was doing well, he suffered no pain whatever, his general condition was good, and there was, api)arently, every likelihood of a speedy recovery. Simple dressings to the wound were continued, and little else was done in the way of treatment. On October 3d convulsions of an epileptic character indicated some grave cerebral complication. An incision was made through the wound, but no injury to the cranium could be found. Wet cups were applied over the temporal regions and blisters to the nucha, and a terebinthinate enema was administered. The convulsions subsided under these measures and did not recur. But there remained a dull pain in the liead, hebetude, and a febrile movement. On October 8th there were rigors, followed by acute pain in the side of the chest. Coma supervened, and death followed on October 13th, 18G4. At the autopsy an ovoid scale of the external table was found necrosed. This was situated beneath the middle of the scalp wound and at the lower posterior angle of the left parietal. The line of dem.arcation was well marked, but there was not the slightest depression of the outer plate. On removing the skull-cap an angular fracture of the internal table was discovered at a point corresponding with the contusion in the outer table. This fracture was depressed to the extent of one line. The dura mater beneath was thickened and ulcerated over a space two inches in diameter. The vessels of the pia mater were much congested. Both the gray and white matter of the brain were softened. The softening was particularly marked in the left hemisphere near the corpus callosum. In the chest firm pleuritic adhesions were found, with effusion on the right side and with old tuberculous deposition at the apices. In the pulmonary parenchyma were several metastatic foci, containing a detritus of blood corpuscles mingled with pus. The lung tissue was friable. The liver was normal; the spleen weighed twelve ounces. The next case is remarkable for the late apparition of inflammatory symptoms. It is noted in the reports of five hospitals ; Case 4. — Private Christian Boucher, Co. C, 118th Ohio Volunteers, aged 19 years, was wounded at the battle of Ees.aca, Georgia, May 14th, 1864, by a conoid.al musket ball, in the occipital region; another ball injured the right t(!sticle. He was at once .admitted to the field hospit.al of the 23d Army Corps. On the register of this hospital the head injury is described as severe; but the symptoms are not particularized, nor the treatment detailed. In a few days the p.atient was sent, by the way of Chat- t.anooga, to Nashville, Tennessee, and admitted to Hospital No. 1 on May 24th. Here the head injury was registered as a slight scalp wound. Nevertheless, the patient remained for a month at this hospital, and was transferred to Louisville, Kentucky, on June 2Gth. The case-books of the Nashville hospital afford no information respecting the progress and treatment of the case. On July 1st the patient was again transferred to Cincinnati, Ohio, where he was admitted to the Marine Hospital. He was found to manifest grave symptoms of cerebral disorder, the nature of which wms not particularly specified in the hospital register. Insensibility, stupor, and indic.ations of inflammation of the brain finally supervened, and the patient died July 14th, 1864. At the autopsy, when the calvaria was removed, it was found that a depressed spicula of the inner table, immedi.ately beneath the wound in the scalp, had penetrated the dura mater, and that there was incipient softening, for an inch in diameter, of the brain tissue, immediately below this wound of the membrane. Apart from this limited result of inflammation, and the engorgement of the longitudinal sinus by coagnla, the contents of the cranium were found in an apparently normal condition. An examination of the chest showed that the heart was healthy, that there was some deposition of tubercles in the lungs, and old and extensive adhesions of the right pleura. The abdominal viscera were healthy, with the exception of a slight enlargement of the spleen, and traces of .subacute inflammation of the lower intestines. But the lesions in the thoracic and abdominal cavities were insufficient to cause, or even to hasten materially, a fatal issue. The record of the case at the Marine Hospital, Cincinnati, is compiled by Assistant Surgeon F. Grube, U. S. V. Case 5. — Private J. W. Patterson, Co. B, 1st Iowa Volunteers, aged 21 years, was wounded at Tupelo, Mississippi, July 14th, 1834, and is reported by Surgeon J. N. Niglas, 6th Illinois Cav.alry, on the casualty list of the right wing of the 16th Army Corps, as having a “dangerous gunshot wound of the head,” produced by a fragment of shell. The patient being conveyed to tile rear, was admitted to Adams Hospital, at Memphis, Tennessee, on July 21st, and died on July 24th, 1864. No particulars of the treatment are recorded, but on the monthly hospital report, signed by Surgeon J. G. Keenon, U. S. V., it is stated that “the e.xternal table, not being in the least fractured, no operation was performed;” and the report goes on to state that the patient presented many symptoms of compression of the brain, yet they were judged insufficient to justify operative interference. Furthermore, that a. post mortem examination was made, and that upon the skull-cap being remov.ed, “the internal table of the cranium was found to be severely fractured, and fragments of bone were pressing on the brain, while several abscesses had formed just under the dura mater.” Efforts to obtain the specimen, or further particulars of the case, have been fruitless. The next case furnished a typical specimen of this rare form of injury : Case G. — David H. P , Co. C, 35th Wisconsin Volunteers, aged 20 years, detailed probably as an orderly, since his regiment was not in the action, was wounded, at the engagement at Tupelo, Mississippi, July 18th, 1864, by a musket ball which struck the skull obliquely, and apparently inflicted a scalp wound merely, between the sagittal suture and the left parietal protuberance. There were no signs of cerebral disturbance. The wound was dressed simply, and the patient was conveyed to Memphis, Tennessee, and admitted into the Adams U. S. General Hospital on July 23d. He was then perfectly rational and free from head symptoms. Two days subsequently indications of compression of the brain were observed, and on the afternoon of the 25th they h.ad r.apidly become aggravated. The pidse was slow, the respiration labored, the pupils dilated. GUNSHOT FRACTURES OF THE INNER TABLE OF THE SKULL. 143 the sphincters relaxed. A very careful exploration of the wound was made, but, of course, no cranial fracture could be detected. The treatment was limited to cold applications 'to the head, scarified cups to the nucha, and brisk purging. On the 2011], the pa- tient gradually became comatose. The discharges from the bowels and bladder were involuntary. Tbe patient coutiiiued to sink on th^27racticable to learn anything of the patient’s condition for the next live days, during which he was in transit to the depot for wounded at Belle Plain ; but, on May 12th, he was sent up the Potomac on a hospital transport, and was admitted to Armory Sejuare Hospital, Washington, comatose and with his wound in an erysipelatous condition. Diligent and repeated examinations of the records and rei>orts from Armory Square Hospital have failed to discover any account of the progress and treatment of the case. Tlie patient died on May 21th, 1864. A segment of the frontal bone was removed and forwarded to the Army Medical Museum by Surgeon D. W. Bliss, U. S. V. Its external and internal surfaces are perfectly represented in Figures I and II of the foregoing plate. The outer table is not fractured; but is porous and softened where the pericranium was scraped off by the jirojectile. A meddlesome dissector bas chipped oft' a bit of the e.xternal table and diploe with a scalpel in the endeavor to ascertain post mortem the degree of softening of the bone. A fragment of the inner table, one and one-fourth inches long, is completely detached. After contusions of the outer with fractures of the inner table, where the pericranium is removed to any great extent, necrosis of the outer lamina occurs if the patient lives long enough, and a thin exfoliation is separated. Tlie Museum possesses several illustra- tions of lesions of this nature, all of them resulting from the very oblique impact of projectiles : Case 9. — Private Conrad S , 54th New York Volunteers, aged — years, was wounded at the second battle of 'Manassas, August 30th, 1862, by a musket ball which produced a scalp wound on the top of the head, across the sagittal suture, *The Report for 1865 of the Adjutant General of Wisef)nsin gives August lOtli as tho date of death. The date above given is tliat entered in tlio official certificate signed by the surgeon in cliarge of tlio-hospitai. \ Maxime.n (Ur Krirgshcilkiinsl, Sd ed. Hanover, 1861, S. .546, I’igiircs lil and 13. 144 WOUNDS AND INJURIES OF THE HEAD, parallel to and an incli bohind the coronal suture. He was admitted to Finley Hospital, at Washington, on September Sd, and died of “inflammation of the brain ” on October 20tb, 1803. The records of Finley Hospital give no particulars of tlie iirogress and treatment of the case, nor of the appearances obsei'ved at the autopsy. A segment of the cranium was sent to the Army Medical Museum by Surgeon Israel Moses, U. S. Vols. It shows an exfoliation of the outer table a quarter of an inch by one inch, the sur- rounding bone being cribri- Fig. .to. — Depressed fracture of the vitreous table of form and sponcry. The thin FIG- 51- — Exterior view of the same specimen, show- the parietals an inch "behind the coronal suture. Spec. , i ^ -i • ing an exfoliation fi'om contusion of the skull. Spec. 64C, Sect. I, A. M. M. oval necrosed scale is not 640, Sect. I, A. M. W. fractured or displaced. The vitreous table is fissured and slightly depressed. The wood-cuts give a satisfactory representation of the nature and extent of the lesions. (Fig. 50 and Fig. 51.). The next case is remarkable for the absence of all symptoms of cerebral disorder until within a few bours of the patient’s death : Case 10. — Private Daniel C , Co. D, 76th New York Volunteers, was wounded at the second battle of Bull Run, August 30th, 1333, by a musket ball wliich inflicted a long transverse scalp wound near the vertex, the greater portion of the wound being over the right parietal. The wounded man was sent to Washington, and thence to Annapolis, where he was admitted to the General Hospital on September 8th. He was suffering from intermittent fever, and this diagnosis was placed upon his bed card, the wound being regarded as trivial in its nature. Treatment was directed to the interruption of the febrile paroxysms, which recurred obstinately in spite of the free administration of preparations of quinia. On September 23d, Assistant Surgeon J. W. Brewer took charge of the patient. The remainder of this abstract is compiled from his interesting notes of the case. The wound looked well at this date, and gave the patient no uneasiness ; it was covered by florid healthy granulations, and discharged, in small quantity, laudable pus. The man had had no chill for twenty-four liours. Quinine was continued in small doses, and a generous diet was ordered. On the following day, September 25th, the patient complained of acute pain over the lower lobe of the right lung. There was no modification of resonance on percussion; and auscultation revealed no alteration in the respiratory murmur. Stupes of turpentine were ordered, and an aperient dose. At noon the pain in the side was much relieved ; but the patient complained of violent pain in the right ankle, and in the foot of the same side. The cause of this pain, or of its location, could not be ascertained. At night, the pain was not relieved, and the patient was becoming very restless and irritable, which led Dr. Brewer to suspect some occult cerebral disorder, and again to examine the wound, and, finally, to request Assistant Surgeon T. H. Helsby, U. S. A., to see the patient with him. A careful exploration of the wound failed to detect any injury of the bone, a granulating surface being everywhere presented. In the absence of any symptoms, except restlessness, that could be referred to cerebral disturbance, it was concluded that the wound had no connection with the existing pain and general irritability, and the patient was ordered to have an anodyne, and a stimulating embrocation to the ankle. On the following morn- ing, September 25th, 1833, coma suddenly supervened, and death promptly ensued. An autopsy was made, two hours after death, by Acting Assistant Surgeon B. B. !Miles. The thoracic viscera were found to be in a normal condition, except that there was inflammatory engorgement, or possibly, hypostatic congestion only, of the lower lobe of the right lung. The abdominal viscera were carefully examined, but no cause of death could be found in that cavity. The calvaria wits then removed. The dura mater was adherent to the bone beneath the site of the wound. A depressed stellate fracture of the vitreous table of the right parietal was discovered near the sagittal suture. A small quantity of pus followed the removal of the calvarium. On removing the dura mater, sev- eral ounces of jnis were found on the surface of the left hemis- phere. On closer examination, an aperture was discovered in the falx, and it became evident that an abscess had formed beneath the depressed fracture, and had burst through the , Repressed fraeture of vitreous table of falx, inundating the convolu- FIG. 53. — Exteriorviewofrhesamespeeimcn.shiw- sek"t a‘!m M. ^ the opposite hemis- ^w^exf.diaUon resuU Spec. phere. The veins oD the lower • extremity, and of the lung wore not examined, and whether the pain in the right foot and light chest were signs indicative of embolic complications resulting from the abscess was not determined. In conchnling his report. Dr. Brewer ag.ain calls attention GUNSHOT FEACTUKES OF THE INNER TABLE OF THE SKULL. 145 to the fact that no symptoms of encephalitis appeared in the case; hut it i.s to be remembered that the chills, which were reported as paroxysms of intermittent fever, did not come under his observation, and that no record of their attendant symptoms has been preserved. The calvaria was sent to the Army Medical Museum by Dr. Brewer. (Fig. 52 and Fig. 53.) The prepara- tion is described in the Catalogue of the Surgical Section, (p. 8.) It is fairly represented in the foregoing w’ood-cuts as the vault of the cranium, showing a contusion of the right parietal bone at the middle of its suiierior border. The outer table is spongy, and a thin plate, one inch in length, is necrosed and i)artially separated. The internal table is fractured and slightly depressed, and shows traces of an attempt at repair. Case 11. — Private Cyrenus Sewell, Co. D, 2d New York Heavy Artillery, was wounded, at the battle of Spottsylvania Court-house, Virginia, May 19th, 1864, by a conoidal musket ball which struck the left parietal bone, near its articulation with the occipital, denuding the cranium for a space one inch in length and half an inch in width. No fracture of the cranium could be detected. He was admitted, on June 1st, to the Summit House Hospital, Philadelphia, complaining of pain in and about the part struck, but was otherwise doing well. On June 9th, he commenced to cough, became feverish, and, at times, delirious, and suffered from pain in the left chest. These symptoms continued for four days. On' the 13th, he was almost wholly unconscious, could take no solid food, and could only with difficulty be induced to swallow fluids. He died on June 14th, 1864. The autopsy disclosed a small collection of pus under the scalp, at the seat of injury. There was no fracture of the external table. The missile had struck over a Wormian bone, the sutures of which were a little loosened, thus admitting a slight depression on pressure. On removing the calvarium, a fracture and depression of the internal table was detected; an angular piece, an inch in length and breadth, was found depressed a quarter of an inch or more. A large abscess was found on the left side of the brain, some distance from the surfoce, and i)us in large quantities had collected under the dura mater. The left side of the brain was highly inflamed. The case is reported by Surgeon J. H. Taylor, U. S. V. Some nosologists would perhaps exclude the following case from the category under consideration, since the outer table was grooved by the projectile which caused the injury. But I think it should find a place here as the outer table was incised rather than fractured, while the contunding force of the projectile was propagated to the internal table. In this as in the preceding case, the injury to the vault of the skull led ultimately to a formation of pus within the skull and to purulent infection probably ; and in both cases the pyaemic symptoms appear to have been masked and mistaken for malarial complications. Case 12. — Private William McP , Co. A, 101st Ohio Volunteers, aged 27 years, was wounded, at the battle of Chick- amauga, September 20th, 1863, by a piece of shell, which inflicted a wound of the scalp three inches long and tw(j inches wide ov(U' the left parietal bone. The pericranium was strijiped off to a somewhat less extent; the external plate of the parietal was furrowed as if by a gouge. The patient’s wound was hastily dressed, and he wms then sent, by railway, to Nashville, whei-e ho was admitted to Hospital No. 1, on September 24th. His general condition was good; his pulse slightly accelerated, counting 90 ; all of the excretions were natural, and there were no head symptoms. He was put upon low diet, and cold water dressings were applied to the wound. There was no untoward symptom until October 3d, when he had slight fever and complained of headache and constipation. The pupils responded readily to light. He was ordered four compound cathartic pills. After being purged he appeared, on the following day, somewhat better. The cold applications to the head and restricted diet were con- tinued. On October 5th, fifteen days after the reception of the injury, he had severe rigors, followed by a febrile movement and profuse sweating. Heiidache had returned with severity. He was directed to take three grains cc. 1922, Sect. I, A. M. M. by fever and coma. A t(‘re- binthinate enema was administered, without efiect. On the 11th, the jiatient was still comatose. The dilated pupils sluggishlv 19 146 WOUNDS AND INJURIES OF THE HEAD, coiifi’acted wtion cxposwl to tlie liglit. Ho was ordored a powder of two and a lialf grains of calomel and tliroe of bicarbonate of soda every four hours. On the 12tb, bis bowels were freely moved, but the cerebral symptoms wore not modified. On the 13tb, the coma was ju-ofound. The pu|)ils were insensible to light. The respiration 15, and pulse 70 per minute. There was paralysis of the bladder. Involuntary alvino evacitations took place. The extrenuties were flexed and rigid. Death occurred on the afternoon of the 14th of October, 18G3, twenty-four days after the reception of the injury. The autop.sy was made ten hour.s after death. The body was moderately emaciated. The external plate of the left jiarietal above and in front of the protuberance W'as deeply grooved for about an inch. About this groove an ovoid necrosed portion of the outer table was separated by a line of demarcation. The calvaria, which was of unusual thickness, was removed and transmitted to the Army Medical kluseum by C. .1. Kipp, Assistant Surgeon, U. S. V. It is numbered 1922 of the Surgical Section. Its inner surface presented a fracture of the vitreous lamina without depression. About the fracture the bone was carious. A thick layer of pus interposed between the bone and the dura mater. Near the junction of the sagittal and fronto-parietal sutures, was an abscess containing two ounces of pus. The dura mater that covered the left hemisphere aud the middle lobe of the right hemisphere was much thickened, and was of a dark greenish color. Along the walls of the longitudinal sinus, adhesions had formed between the dura mater and cerebral layer of the arachnoid. The longitudinal sinus was filled with coagula, and fringed with pseudo-membraneous exudation. The superficial cerebral veins were tinged ^vith black blood. The grey substance of the external convolutions of the anterior and middle lobes of the left hemisphere, and of limited portions of the right hemis(diere, W’ere soft, and of a greenish color. There were no abscesses in the substance of the brain. The lateral ventricles contained about two fluid ounces of bloody serum. All of the tho- racic and abdominal vicera were examined; but no abnormal appearances were observed in them. A segment of the diseased dura mater constitutes the preparation numbered 1923 of the Surgical Section of the Museum. Its external surface displays a dark dis- coloration over the surfiice corresponding with the necrosed portion of the calvaria. (See ITg. 5(5.) Its inner surface, likewise, is discolored over a space five inches in length aud three inches in breadth, which is covered by an exudation of false mem- brane. Near the longitudinal sinus are numerous fungous tufts, in several of which bone has been developed. In the next case, also, the efforts of nature to repair the vault of the cranium were fi’ustratecl liy the supervention of inflaminatory mischief within the skull. Cask 13. — Sergeant William H. 15 , Co. K, 47th I’ennsylvania Volunteers, aged 24 years, was wounded at the battle of Cedar Creek, October 19th, 18C4. He believed that he was struck on the top of the head by a fragment of shell; but the wound had more the appearance of an injury inflicted by a musket ball. His name appears on the casualty lists, with the entry “ flesh wound of the head — slight.” He was sent to Newtown, and was thence transferred to Satterlee Hospital at Philadelphia, where he arrived on October 2.5th. A scalp wound two inches long was found about an inch behind the coronal suture and parallel to it. It extended further to the left than to the right side. The bone was denuded of periosteum over a space an inch long and half an inch wide. The bone appeared to be otherwise uninjured. The pupils were dilated, and the right side of the body was partially paralyzed. The patient complained of no pain; his ai)petite was good; he had slight diarrhoea. It does not appear that his diet was restricted, and no record is made of the measures adopted to combat the s3miptoms of compression of the brain. On October 27th, he had involuntarj^ fiecal dejections, and more stupor, and hemiplegia was complete. He had a slight rigoi' on this day. On October 28th, he had a severe chill and his “appetite began to fail.” Coma supervened, but tbe patient lingered a week longer, death taking place on November 5th, 18o4. No de- scription of the post mortem examination has been furnish- ed. The skull-cap w'as sent to the Army Medical Museum. It shows externally (Fig. 58) the efieets of a contusion of the outer table of tbe skull. A line of demarcation includes FI(3. .W. — Dei>rosso(t fracture cf the inner tal)Ie nf tlic an ellijitical partially necrosed skull fnun a contusion of tlie out(‘r table. Spun. '.JOSlt, , . -.it . x* • * Sect. I A. M. M. plate witli diameters of an incti and a quarter and of three- fourths of an inch. The internal table is fissured, aud there are the marks of diseased action along the groove for the longitudinal sinus .as far backward as the occipital hone. (Fig. 57.) Acting Assistant Surgeon Henry Mullen contributed the specimen, which is represented in the wood-cuts above. Fig. 58. — Exterior view of the same specimen, showing superficial exfoliation. Spec. 3039, Sect. 1, A. M. HI. PlG. 5(i. — I’ortion of tlie dura mater covered witli pseudo-membrane. Spec. 1933, Sect. I, A.M..M. GUNSHOT FEACTURES OF THE INNER TABLE OF THE SKULL. 147 No casos of gunshot fractures of the inner table of the skull without external fracture have been noticed in the reports of the Confederate army medical department that have been filed in this office ; but the following case, and another, recorded on page 148, pertain to Confederate prisoners who died in Union liospitals : Case 14.— Private James 21. B , Co. D, 17tli Virginia Infantry, 17 years of age, was wonnded, at the battle of Spottsylvania, Hay I’ith, 1834, by two couoidal muslcet balls, one of which passed through the lower portion of the right arm, gra/.ing the outer surface of the shaft of the humerus, while the other denuded the bone on the upper left side of the forehead. He was taken prisoner, and was sent to Philadelphia, where he was received at Satterlee Hospital on May 20th, and placed under the care of Acting Assistant Surgeon M. Lampen. His general health was quite good ; and the wounds were granula- ting kindlv. He was allowed to be up and to walk about, and to have ordinary diet. On May 28th, he complained of head- ache ; he liad a slight febrile movement, and was constipated. The headache and feverishness persisted on the three following days, and on the 31st, there was a slight chill at t\vo in the afternoon, followed by a severe rigor at five o'clock. A febrile reaction ensued lasting about an hour, after which the skin was cold and moist. The pulse was full at 84 ; the pupils were contracted ; there was stupor but no paralysis ; the tongue was heavily furred. During the three following days, there \vas active delirium, alternating with stupor and occasional lucid intervals. When conscious, the patient complained of pain in the head and abdomen. During this period the pulse averaged 110, and was weak and compressible. On June 5th, the left side of the fiice was oedematous. The patient was tolerably quiet. The urine and fteces passed involuntarily. On June 7th, the pulse was fluttering and very frequent. Profound coma supervened about one in the afternoon, and continued until tlie patient’s death, which took place early on the morning of June 8th, 1864. From the date of accession of the headache and febrile phenomena on May 28th, the treatment consisted of brisk purging, the use of diaphoretics, cold applications to the head and revulsives to the lower extremities. Thirty hours after death, an autopsy was made by Acting Assistant Surgeon Charles P. Tutt. At the junction of the lower and middle thirds the right humerus was denuded of its periosteum. The wound on the forehead W'as an inch and a (juarter in length and half an inch wide. On laying back the scalp a large amount of jjus was found beneath it on the left side. The external table of the skull was not fractured, but above the left frontal protuberance, where the thin pericranium was extensively separated fig. GO. — Extericir view of the same srecimen, showing Fig. 59. — Fissure of inner table of frontal bone, from a , f the spongy te.vture of a contusion near the left frontal gunshot contusion, 2747, Sect. I, A. M. M. t>y me ouiiotvlllj, oi pus, en,inence. .Spec. 2747, Sect. I, A. M. M. the bone was spongy and discolored. On removing the skull-caji, the internal surface of the cranium corresponding with the wound was found discolored, tind presented a linear fissure an inch long without any depression of its edges. The dura mater beneath this space resembled a dark eschar in appearance, and tvas coated with pus. There was a considerable amount of pus upon the suiTace of both hemi- spheres. The vessels of the pia mater were much congested, and at the base of the brain there was a large effusion of serum. In one or two places in which the results of meningeal inflammation were conspicuous, the subjacent cerebral convolutions were superficially altered, in color and texture. But the greater portion of the hemispheres, the ventricles, the cerebellum, pons Varolii, and the medulla oblongata were normal in appeaiance. Near the apex of the left lung, masses of unsoftened tubercles were found ; there were extensive pleuritic adhesions, and a large amount of sero-purulent fluid in the cavity of the left chest. There were three large metastatic abscesses in the right lobe of the liver. The kidneys were enlarged and presented thi! appear- ance of the first stage of fatty degeneration. The specimen and memorandum of the autop.sy were contributed by Dr. Tutt. The next case is remarkable, as it appeared to indicate tliat a gunshot fracture of the inner table alone of the frontal bone may be caused by the oblique impact of a itrojectile upon the superciliary ridge. It is probable that the blow was not over the sinus, but upon a portion of the bone supplied with diploe. Case 15. — Corporal William McCord, Co. I, 14th Michigan Volunteers, at Chattahoochie, Georgi.a, July 5th, 18C4, was struck over the right superciliary ridge by a conoidal musket ball. He was scarcely aware of being wounded, so slight were the immediate effects of the injury. The bleeding obliged him to leave the r.anks, and he was examined by Surgeon Edward Batwell,* 14th Michigan Volunteers, who stated that he had been struck by a glancing ball, which had cut through the integuments, aiiparently leaving the bone intact. He went to a division hospital of the Fourteenth Corps; but tliough com- plaining of slight headache, he returned next day voluntarily to duty with his regiment. On the eighth day from the reception of the injury, in consequence of severe pain in the seat of the wound, he reported at the hospital. Next day the pain was diminished, and he felt considerably better, but had irregular chills through the day, followed by slight fever. On the morning Surgeon K. llatwell has published an i^couut of this case iu the Michigan Unioersity Journal., Vol. 1. No. 5. July, lb7(). page ii70. 148 WOUNDS AND INJUKIES OK THE HEAD of tliu t(!ntli (lay lie was very' drowsy and snappish, and evening bronglit an increase of these sy'inptoins, and at night he was comatose and insensible, and death cnsnecl soon after. According to Surgeon Katwell’s dates, lie died on July Kith ; but the report of the adjutant general of Michigan and the register of the Fourteenth Army Corps agree in giving the date of death as July 28th, 1864. • A post mortem examination revealed a fracture of the inner table of tbe skull, with slight depression, though none was visible on the external surface, with an abscess, containing about two ounces of pus, under the seat of injury and in the substance of the brain. Dr. Batwell remarks; “The curious points of this case are the absence of urgent symptoms during the first nine days, and the rapidity of their development within the last twenty-four hours.” Ill the four following cases of gunshot fracture limited to the inner table of the skull, tre]4iining was unavailingly performed. In all of them the exact nature of the cause of the cerebral compression for which the operations were performed was necessarily only conjectured, and perhaps in Case 17, only, was the existence of a fracture of the vitreous table surmised. The operations were performed on general surgical principles to relieve compression of the brain. That they were unsuccessful, only corroborati^s the opinion that has been so strongly impressed on the minds of surgeons of the present day, that authentic examples of successful trephining for matter between the bone and dura mater are now very rarely cited. It will be noticed that those who died from encejdialitis survived from ten days to a fortnight, while those who died from abscess of the brain lived about three weeks ; Case 16. — Private William Casey, Co. 11, 60th Ne(v York Volunteei’s, was Avounded in the head at the battle of Fair Oaks, Virginia, June 1st, 1862. He was admitted to the regimental field hospital, and thence sent, on an hospital transport steamer, to Philadelphia, where he entered the South Street Hospital, on June 8th, being insensible on admission. There was a lacerated wound of the scalp, near the right parietal eminence, but no fracture of bone could be detected. Cold water dressings .and adhesive strips were applied, and on the next day the patient aroused and became quite rational. On the afternoon of tbe 12th, he manifested much nervous anxiety, Avith nausea and retching. He soon afterAvards had a violent chill. His head Avas V'cry hot, and the pupils Avere contracted. The adhesions of the Avound Avere broken up, and cold applic.ations Avere made to the head. There Avas little change in his condition until June 1.5th, Avhen the stupor and other signs of cerebral com- pression became more marked, and it Avas decided to apply the trephine. A button of bone Avas removed. Upon perforating the skull an immense amount of sanious pns floAved through the orifice, but the condition of the jiatient Avas not ameliorated. He remained comatose until death, Avhich occurred on June 16th, 1862. A careful post mortem, examination reve.aled a fractui e of the internal table of the cr.anium, and an immense cerebral abscess involving all the convolutions and the pia mater of the right hemisphere. The case appe.ars to h.ave been attended, and the operation performed, by Acting Assistant Sni'geon J. Hopkinson ; but, unfortunately, no special report Avas made, and the disposition made of the specimen is unknoAvn. The Army Medical kluseum Avas not then est.ablished, and this, and many other pathologic.al preparations obtained at the time, probably ])assed into private h.ands. The facts above recorded are gleaned from the monthly rejiort, prescription book, and case book of the South Street Hospit.al. Case 17. — Priv.ate Dennis S , Co. E, 2d West Virginia Cav.alry, aged 21 years, was Avounded, in an engagement at Harper’s Farm, ne.ar Appomatto.x Court House, on April 6th, 1865, by the obliipie impact of a musket ball Avbich denuded and contused the front.al bone a little beloAV the coronal suture and to the left of the median line. Being taken prisoner, he Avas [daced in a field hospital Avhero a Avater dressing Avas aiiplied, the hair being sh.aved off to a suitable extent. A fcAV days subsequently, be was sent to the re.ar, and he re.ached Washington a fortnight after the reception of his Avound, and AV.as ])laced in Harewood Hospital on Ajiril IDth. He had a chill soon .after his admission, and reported that for some days he h.ad suffered from tAVo p.aroxysms of ague daily. He had no pain in the head, nor any symptom to e.xcite apprehension .as to the condition of the br.ain, except the chills, Avhich Avere ascribed to m.alarial intluence. They proved, hoAvever, not to be amenable to quinia, Avhich Avas freely administered, for several days, Avithont adv.antago. On April 24th, a slight congestion of the loAver lobe of the light lung Avas noticed. The next d.ay pneumonia Avas fully deA'eloped here, and on the 26th, the greater portion of the light lung Avas involved, and there was acute pain in the cardiac region, Avith a souffle accompanying the first sound of the heart and a murmur of regurgitation the second sound. The pulse rose rapidly to 1.56; but fluctuated greatly in frequency and force. At ten jn the evening of this day the patient became comatose. Shortly aftei-Avards, Surgeon li. B. Bontecon, U. S. Vols., apjilied the croAvn of a small trephine on the right of the space in Avhich the pw'icranium Avas removed. When the outer table Avas passed, pus began to exude from the cells of the diploc. When this Avas pene- trated a depressed fracture of the inner table Avas discovered. Another perfora- tion Avas now made to obtain sp.ace to remove the d(>pressed fragments of the vitreous jilate. A small fragment and another nn'.asnring nine by six lines Avere found completely detached, and Avere removed by common dissecting forceps. The operation had no inlluence iqion the profound coma, that persisted until the patient’s death, Avhich took place on the folloAviug morning, Ajiril 27th, 1865. At the Fig. 61. — Seg’ment of a cranium trephined for a dejiressed fracture of the inner table. 4344, Sect. I, A. III. M. GUNSHOT FRACTURES OF THE INNER TABLE OF THE SKULL. 149 a.nt()psy, .i large abscess was found in the substance of tlie right cerebral homisnhere. A segment of the' frontal l)onc, with the two disks and the larger fragment of the inner table, removed at the operation, were forwarded to the Army Medical Museum, by Surgeon R. B. Boiitecou. U. S. V., and are represented in the accompanying wood-cut, (Fid. Gl.) A view of the interior of the specimen is given in Fig. I, of the Catalogue of the Surgical Section of the Army Medical Museum, (p. (5,) and in the Surgical Report in Circular No. 6, S. G. O., 1835, j). 11, Fig. C, and a photograph of the patient, taken a few hours prior to the operation, is preserved at the Museum, as No. 58, Vol. I, of the Series of Contributed Photographs of Surgical Cases. The lower figure in Plate III, opposite page 105, is copied from the photograph, and represents the a])pear.ance of the |)atient after the graver sym))toms of compression of the brain had set in. Ca.SE 18. — Privuato Charles H. Leonard, Co. II, 57th M.assachu setts Volunteers, aged 22 years, was wounded, ,at the battle of the Wilderness, Virginia, May G, 180-1, by a conoidal musket ball. He was conveyed to AVashiugton, I). C., and, on May 11th, admitted to the Columbian Hospital. There was a wouml of the scalp over the left occipital ))rotuberance, but the external table was not fractured. On* May 15th, Acting Assistant Surgeon H. 1). Vosbnrg ap])lied the trephine, removed a portion of bone, and took out a fragment of the inner table, which was lying loose on the dura mater. Coma supervened, and death occurred on May 17th, 1834, from encephalitis. Ca.SE 19. — Private John R. Montgomery, Co. A, 9th Illinois Volunteers, aged 30 years, was wounded, at the siege of Fort Donelson, Tennessee, Fe^ ■nary 14th, 18G2, by a buckshot which inflicted a scal]i wound over the right ])arietal bone, .and lodged. Three days after the reception of the injury, the iiatient was admitted to the hospital of the 2d division of the Fifteenth Corps. An examination of the wound revealed an opening in the scalp of the size of a pea. The missile could not be defected by the probe. There w.as no depression of the skull, and oidy a slight denudation of the pericranium coidd be discovered. The patient felt well, ate heartily, was able to walk about the ward, read neivspapers, and considered his wound of slight importance. On Febru.ary 19th, he was .attacked with clonic spasms of the left side of the face and left extremities. They recurred about every ten minutes at first, and rapidly augmented in freejuency, becoming, in an hour, almost continuous. Trephining was determined upon, and the patient being placed under the influence of chloroform, the scal|) W'as rellected. A portion of the skull of the size of a shilling was found to be denuded of periosteum and somewhat roughened, but no fracture or depression was evident. Upon ])erforating the e.xternal table, the inner table was found to be broken and sj)lintered to a considerable extent. A clot of blood was found upon the membranes of the brain, and on its removal the yaitient aroused and bec.ame conscious, without recurrence of the convulsions. The splintered portions of the internal jdate were removed, the scalp was replaced, and simple dressings were applied. On the two days following, the [).atient was doing well, and the spasms did not recur. Early on the morning of February 22d, convulsions suddenly came on again ; but ceased when Dr. Fisher explored the wound with a probi;, and removed some coagula. On the 23d, the convulsions recurred, and soon became almost incessant. There were short lucid interv.als during the day, when the j)!itieut conversed rationally; but he was evidently becoming comatose, and answered questions with much difficulty of articulation. On the 24th, a consultation was held by Urs. Fisher, Boone, and Heydock, and it was decided to remove another portion of the skull. The patient was chlorofoiined, and Dr. Fi.sher apidied the trephine and removed a button of bone from the anterior edge of the perforation previously made. The wound was cleaned with a syringe, the patient rallied, the convulsions ceased for si.x or eight hours, and (ho symptoms improved. The wound began to discharge freely; but drowsiness and insensibility c.ame on, and the p.atient went into a ]irofounil coma, ami died on the afternoon of February 25th, 1832, eleven days after the recej)tion of the injury. The next case is a very remarkable example of contusion of tlic occipital bone by a musket ball, without apparent injury to the outer table, and with de[)ressed fracture of the inner table, followed by an exfoliation of the entire thickness of the bone that had been divested of its periosteal covering. This patient was the solitary survivor of this form of injury in whom the diagnosis could bo verified : Case 20. — Priv.atc .John Donov.an, Co. I, 97th Pennsylvania Volunte. 210. '^Cooper, Surgical Dictionarg, 8th ed., p. 899. IIennex, op. cit., ji. 327, and Brodie, in Med. Chir. Trans., vol. XYI, p. 231. ‘'Baudens, Clinique dcs Plaks d’Armes d Feu. Paris, 183G, p. 80, 152 WOUNDS AND INJURIES OF THE HEAD, Bernhard Beck' relates the case of a soldier of the Pope’s second Swiss regiment, who had, at Vincenza, a contusion by gunshot of the right parietal, making a scalp wound two inches long, denuding the periosteum. There was paralysis of the left arm. The patient died two days after the reception of the injury. The internal table was depressed. Four splinters penetrated the dura mater. A collection of pus lay beneath the seat of injury. Beck also gives the particulars of two other cases that of a man who received a blow on the left parietal from a beer glass, which produced a fracture of the inner table. Meningitis followed by intracranial suppuration and death ensued. The second was a soldier of the Grand Duchy of Oldenburg, who received a lacerated gunshot wound of the scalp over the right parietal. No cerebral symptoms at first ; but in three weeks meningitis and pyiemia ensued and the patient died. The autopsy showed a fracture with depression of one line of the inner table. The dura mater was separated from the bone, and there was an abscess beneath in the cerebral substance. There were also metastatic foci in the liver and lungs. OchwadD records the case of a Danish soldier who received in the Schleswig-Holstein war, an oblique gunshot wound over tlm left parietal ; the scalp being much torn, and the periosteum denuded. There was nothing noticeable about the case until the fifth day. Death resulted on the seventh day from encephalitis. The autopsy showed a depression of the internal table of the size of a grosclien. Near the upper anterior angle of the parietal, there was a small abscess beneath tlie cranium and dura mater, at the seat of injury. Guttenberg' records the case of a soldier of the second Baden regiment, who, at Rastadt, August 4, 1861, received a blow from the lock of a musket over the right parietal protuberance. The scalp was torn and the periosteum abraded. He had headache and slight fever, but no cerebral symptoms of consequence until August 22d, when convulsions occurred, followed on the 24th by hemiplegia of the right side. Death took place on August 28th. A fracture of the inner table three lines in diameter and depressed one line, without any visible fissure of. the outer table, was observed at the autopsy. Guthrie'’ has carefully examined the literature of this subject, and adds an interesting case which Mr. Deane of Chatteris, in Cambridgeshire, had occasion to. observe in a young man — a fracture of the inner table from a blow below the left parietal protuberance. There was a slight detachment of the pericranium, but no external fracture ; yet on the removal of the calvaria, when the man died, a few days after the injury, a distinct fracture of the inner table about three-quarters of an inch long, was found corresponding to the external part injured, and extending to the diploe but no I'urther. There was an extrava- sation of blood beneath, between the bone and dura mater. Guthrie® also details a case of injury of the internal table without lesion of the outer, related by Mr. Trye,”' of Glouces- ter, successfully treated in the year 1786. Nine weeks after contusion of the right parietal, the external table being evidently dead, the trephine was applied, and he then found that ' Beck, Z)ie Schusswunden. Heidelberg, 1850. S. 99, utid Uher isoUrten Bruch der Glastafel in Langenbeck’.s Areliiv. Berlin, 1862, B. 2, S. 547. ^ Beck, Kriegschirurgischc Erfaliruiigen. Freiburg, 1867. S. 167. OciiWADT, Kriegschirurgischc Erfahrungen. Berlin, 1865, S. 321. ■' GuTTEXBEUCf, Uchcr Schddelbriiche mit Eindruclc, in Langenbeck's Arebiv. B. IV, S. 596. ^Guthrie, Commentaries, Sixth cd. London, 1855, p. 342. Guthrie, Op. Cit. — Injuries of the Head, etc., quarto. London, 18.52, p. 73. •Trye, Medical Communications. London, Vol. II, 1790. a UNSIIOT' FRACTURES OF THE INNER TABLE OF THE SKULL. 153 the inner table had been removed liy absorption. There were granulations springing up, but whether from the dura or pia mater, or brain, could not bo accurately ascertained. This man recovered. La Motte‘ supposed that vdien the inner table was broken without the outer, the fact might be ascertained by the peculiarity of the resonance of the skull on percussion resembling the “cracked pot” sound, described in modern times by auscultators of the chest, and cites a case in illustration of this idea. Atthalen of Besan^on had the same opinion, and adduced an interesting case, which happened in 1746 ; but it appears that in this instance there was a fissure of the external table. Professor Stromeyer" also attaches value to this mode of exploration. His remarks on the subject are quoted at length, and possess a special interest, as he reports two of the limited number of cases in which the pathological preparation was preserved : “ This kind of injury, of which only one case has come to my notice, might be observed oftener if we still used the trepan as Pott did, or if one could obtain a reliable diagnosis without opening the cranium. By means of percussing with a silver probe, I was enabled in one case, where there was only a barely perceptible fissure in the outer table, to diagnosticate the extent of the inner separation accurately, and after the decease from pyaemia, in this same case, many of the young surgeons had the opportunity of convincing themselves of the correctness of my diagnosis. Any one of them, who possessed a practiced ear, could discriminate the sounds when percussing the outer table at the point of the internal fracture, or at other parts on the cranium. At the point of the internal fracture, the pitch is somewhat higher. Lanfrancus and Ambroise Pare, I find, already knew of this diagnostic expedient. It is wonderful that the inner table can be fractured and driven inwards considerably, while it is impossible to detect the least injury on the outer table by means of a lens even, as is the case in my specimens. At the same time, these cases are not isolated. Partial fractures of bones by bending are analogous to them. The outer table evidently possesses a greater elasticity and is more pliable than the inner. One can form a good idea of the elasticity of the skull, as Hyrtl says, by throwing a fresh cranium on the floor, when it will rebound. These inner separations remain generally undiscovered, which is, in my opinion, lucky for the patient, because thereby he escapes the danger of being trepanned. It is not assuming too much to suppose that these cases, would generally result favorably, if the patient was subjected sufficiently long to an antiphlogistic diet ; because the danger incurred by these cases is evidently less than in others, where the access of air to the splintered part of the inner table takes place. For the older surgeons, who did not know the difference between subcutaneous wounds and those exposed to the atmosphere, the lesions in cases of head injuries formed a constant source of anxiety. They could not explain to themselves what would become of the secretion of the wound. We now know that when the atmosphere is excluded, and proper care is taken, the inflammatory exudation will become reduced to a minimum, sufficient only to permit the healing process ; while it will never become so much as to require an exit channel. One need not revert fifteen years in surgical literature to be convinced that an unfounded dread of the impossibility of an exit for the secretions of the wound were then considered proper indications for trepanning. The ample information which one of the most zealous advocates of trepanning, one who was an excellent surgeon as well as a truthful man, I mean Percivall Pott, has given us in regard to the effects of trepanning, leaves no doubt as to the theory that the access of air increases suppuration. In most cases ’of simple contusions, in which he trephined on account of the formation of pus internally, very little pus was found at the first operation ; ‘ La Motte, Observations de Chirurgie. T. II, p. 303. -Stromeyer, Op. cit. — Maximen, U. S. V. Zweite Auflagu, S. 331, uiul 543, und 549. 20 154 WOUNDS AND INJURIES OF THE HEAD, Kkj. (M. — Inrijncnt exfoliation of the outer table of the os -lAAof/A-p FiG. 65. — Gunshot fracture of the inner table of the frontal bone*. f'rontis. [After STUOMKYlcii.] UUltllUcllCI. [After Stuomkyek.] y(‘t the symptoms were generally aggravated, and trepanning was resorted to a second or third time, and not until the secondary operations were great quantities of pus disclosed. Tims, as usual, one mistake brought about another, and one ill-advised use of the trephine rendered its repetition necessary. The main symptoms which seemed to demand trephin- ing, for the majority of surgeons addicted to the trephine, consisted in the stupor or insensibility of the patient. It really requires no small degree of firmness of conviction of the danger of the trephine to see a patient, not only for days but weeks, in a state of greater or less stupor or insensibility without resorting to the operation, when, sometimes, complete consciousness is restored immediately by a successful elevation of the depressed bone, or the removal of extravasated blood. It is not enough to remind one that patients with typhus often remain for weeks in a still deeper stupor, and yet gradually resume the use of their mental faculties ; nor is it sufficient to recall the innumerable cases where trepanning, notwithstanding the apparent success of its purpose of elevating depressed bone, or removing extravasations, did not influence the restoration of consciousness, but where this was only gradually regained by means of an antiphlogistic treatment. One must have observed as often the successful cure of head injuries, without trepanning, to be enabled to acquire such accuracy of observation, as nearly every physician possesses in regard to fever patients. Would not every one be called a miserable quack now-a-days, who would give a typhus patient musk, camphor, or serpentaria on account of stupor? It will not be long before no favorable estimate will be had of any surgeon wlio will use the trepan on account of comatose conditions alone. The campaigns of 1849 and 1850 have, happily, given many young surgeons the opportunity to convince themselves, with their own eyes, that one may look on a condition of semi-stupor for weeks without resorting to the trepan.” Dr. Stromeyer, in a later portion of his work, figures two examples of this form of fracture and gives the histories of the patients. One was a man who received a gunshot wound of the scalp in Schleswig, April 13, 1849, making a long groove to the left of the sagittal suture. He was sent to Flensburp;, the following day. He Fig. 63. — Gunshot fracture of the iniKjr table of the left parietal. [After STllOMEYEU, Maximoi, Fig. 16.] vomited several times, and was drowsy and complained of headache. His pulse was weak and slow. On April 15th, he was bled, and the venesection, with a saline mixture internally, was repeated on the 17th, and the wound was enlarged and traversed by a crucial incision. On the 18th, erysipelas appeared, and the cold a})plications cm])loyed were replaced by cerate dressings. On the 22d, the swelling and headache had greatly diminished. On the 24th, there was difficult respira- tion, and the patient was again bled from the arm. He died on the 25th. Blood and pus were found be- neath the GUNSHOT FRACTUEES OF THE INNER TABLE OF THE SKULL. 155 Dr. Stromeyer attributes the death to pya3mia. The other case, that of a soldier wounded at Friedericia, July 6, 1849, was fatal in seventeen days. A conoidal ball had grazed the forehead, and had removed the pericranium, but had not fractured the outer table, which showed only the “ beginning of a necrosed line of demarcation around the bloodless contused part of the bone;” but the autopsy revealed a portion of the inner table lying upon the dura mater. This patient had no head symptoms for eight days, when there was lieadache and nausea. He was twice bled and took calomel, and mercurial ointment was rubbed in. On July 20th, there was slight ptyalism. He died on July 23d. Dr. Stromeyer observes that this case proves the inefficacy of antiphlogistics in pysemic inflammations of the brain. The pathological preparation is represented on the preceding page (Figs. 64 and 65) as figured in Dr. Stromeyer’s work.^ There are several other examples of fractures from external violence of the inner table only of the skull in which the pathological specimens have been preserv^ed. One is num- bered 29, A, in the Dupuytren Museum.^ It is the calvaria of a young man who was struck in June, 1848, during the Revolution in Paris, by a musket ball, fired from an upper window of the barracks at Pv^euilly. There was a furrowed scalp wound over the occipital an inch and a half in length. The skull was denuded, but there was no alteration of color or solution of continuity in the outer table. For a fortnight there were no cerebral symptoms ; then ptosis, partial left hemiplegia, and nervous agitation with fever supervened, and on the twenty-fifth day, brain symptoms were so urgent that M. Denonvilliers trephined over the spot struck, evacuated about three ounces of offensive sanguinolent puriform matter, found beneath an oblong detached fragment of the internal table so large that it had to be divided by bone-forceps before it could be extracted through the trephine hole. The patient died from encephalitis six days after the operation. M. LegouesP states that he brought from the French Army in the Crimea an excellent example of this form of fracture, in which adherent fragments of the inner table of the parietal were depressed in a conical form. Mr. Cowan, ‘‘ Assistant Surgeon of the 55th British Infantry, presented to the Museum at Fort Pitt, a calvarium of a soldier, with a linear fissure of the inner table along the upper edge of the right parietal, the skull having been denuded externally but not fractured. ' Dr. Stromeyer remarks that at the autopsy : “A firm organic connection was observed, of tlie separated portions of tlie inner table with the dura mater, which was not even separated by the process of suppuration that had taken place in tlie neigh- borhood. This observation seems to prove that such detachments of the inner table need not excite such grave apprehensions as heretofore, since the pieces may retain their connection with the dura mater and do not necessarily assume the character of foreign bodies. Has not Walther proven that the inner table from which a portion has been trepanned can again be restored ? A case, of which Dieffenbach justly speaks as being of great physiological importance. Guthrie did not comprehend Walther’s idea of restoration of a trepanned segment, when he says that ‘ the patient had recovered in spite of his doctor.’ Tlie fiiilure in the treatment of my case occurred undoubtedly in the first eight days, during whicli the patient was said to have been in a good condition. Pott would have undoubtedly trepanned in this case, but what modern surgeon would expect success in a case in which tlie autopsy revealed an abscess in the liver?” Op. cit. S. 546. Compendium, de Cldrurrjie Pratique. T. II, p. 573. This specimen is figured at page 283 of M. Legouest’s Traitd do Chirurqie d’Armee. ^Legouest. Op. cit. p. 283. I think the specimen is now deposited in the collection at Val de Grace. ■•See Williamson’s dfiZitary Surqerij, p. 29 ; Holmes’s System, of Suryery, vol. II, p. 47. The patient, Private James Burke, aged 19. received, August 24th, 1855, before Sevastopol, a wound which grazed his head on the side of his seal)), from a musket ball. He walked from the trenches to the field hos])ital. The bone was found bare, but no fracture or depression could be discovered. There were no general symptoms of serious injury of the head. The seal]) was shaved and cold water dressings applied. Five days subsequently the wound became unhealthy and there were slight hemi|)legia on the left side. Convulsions and coma followed and death on the thirtieth day after the injury. At the autopsy, the usual signs of meningitis were observed, and a coagulum the size of a walnut was found under the parietal protuberance. Thu fissure, limited to the internal table, ran ])ar.allel to the course of the ball. The s|)ecimen is No. 2893, in the Surgical Museum at Netley. 156 WOUNDS AND INJURIES OF THE HEAD, Mr. Proscot t llewctP reports, in an analysis of sovcnty-ciglit cases of injuries of the liead, examined after death at St. George’s Hospital, in the decennium from January, 1841, to 1851, that three examples of fracture of the skull, with depression of the inner table alone, were observed. In two, the depression was so slight that it might easily have escaped notice ; in the third, the fracture of the inner table was extensive and the depression considerable. Mr. Edwards,^ in August, 1862, presented to the Medico-Chirnrgical Society of Edin- Imrgli, a specimen of a fracture of the inner table alone of the right temporal bone, from a young lad. The injury was caused by a blow from a cricket ball. There was a slight bruise of the scalp externally, and a crack extending some distance on the internal plate, crossing a canal in which the middle meningeal artery ran. A bit of bone was detached, and the artery was torn across at this point and much blood was extravasated. Demme^ states that he saw a case in which a piece nearly two inches square of the vitreous table was detached, by the oblique impact of a musket ball, while the outer table was uninjured, and that he had preserved the preparation. In a paper on fractures of the skull in Virchow’s Archives, Dr. Hermann Eriedberg,"* of Berlin, reports an interesting specimen of fracture of the inner table alone of the frontal, from a sailor boy of seventeen years, who fell through a hatchway into the hold of the vessel. Bonetus,® in his Sepulchretum, states that Cortesius had a skull in which the inner table was broken, without any sign of a fracture externally having ever taken place. These are all of the examples that I have collected of cases of this kind of fracture, in which the pathological preparations were preserved. It would be possible to glean from ancient authors more examples of this form of fracture, and references to some of them may be found in the foot note.*’ But a sufficient ^ Medico-Chirurr/ical Transactions. 2d series, vol. 18. London, 1853, p. 338. Tlie specimen in the third case is preserved, I believe, in the Museum of St. George’s Hospital. See the 8th edition of Cooper’s Dictionary, p. 889. Editihurgh Medical Journal. Vol. 8, part 1, 1862, p. 191. Edinburgh, 1863. ^ Demme. Specielle Chirurgie der Schussiounden nach erfahrungen in den Norditalienischen Hospitackm von 1859. Wurzburg, 1881, S. 38. ■‘Viiicnow. Archiv fiir patJiologische Anatomie und Physiologic. Berlin, 1861. B. 22, S. 84. ® Tiieopiiilis Boxetus. Sepulchretam, sive Anatomica Practica. Ed. altera by J. J. Mangetus. Folio, Geneva, 1700. 8 Other cases are reported by Scultetus, {Armamentarium Chirurgicum. Editio tertia, Ilagm-Condtum, 1662, 8vo, p. 212. Ohs. XV and XVI,) who describes the injury as “ rima et depressio cranii lamina: interioris exteriore salra;” by SOULIEII, of Montpelier, in the Memoires dc V Academic de Chirurgie, ed. 1819, T. 1, p. 158; by Salmutiiius, (Observationum Medicarum Ccnturice tres. Brunsvija;, 1648, p. 14;) by PLiVTXER, (Institutioncs Chirurgia: rationalis. Lipsim, 1758, p. 286;) by Batting, {Chirurgical Facts relating to Injuries of the Uead. Obs. VIII;) by Smethius, {Miscellanea. Liber X, p. 570;) by Doring, (Nassauische Mcdicinischc Jahrbiichcr, p. 308;) by Kuiik, {Fust’s Magazin, B. XL, S. 58.) Examples of this form of fractures are ascribed also to ArC/EUS, {Dc recta curandorum Vulncrum ratione, cap. 3, p. 17. Amstelodami, 1658;) to Valleriola, {Observationum AferficiaaZiam, lib. 6 ;) and to Borel, {Ilistoriarum et Observationum Ccnturice 2, Obs. 20. Frankfort, 1676;) but they do not appear, from the descriptions of those authors, to have been fair illustrations. Mr. Guthrie remarks that: “The records of eighteen centuries have jiroduced but little information on this most interesting subject; and if the cases were collected which I have overlooked, as well as those which have been altogether omitted, I apprehend that very little more would be gained. I therefore think it safe and reasonable to come to the conclusion, that although these things have happened, they will rarely occur again. I have never, in the great number of broken heads I have had under my care on many different, and grand occasions, actually known the inner table to be separated from the outer, without positive marks of an injury having been inflicted on the bone or pericranium, however slight that injury may have been; and although it is not possible to doubt the fact of fracture of the inner table having occurred, it is very desirable in a practical point of view not to bear it in mind ; for if a surgeon should be prepossessed with the idea that the inner table might be so readily fractured, and separated from the diploo placed between it and the outer table, and thus cause irritation or pressure on the brain, few persons who had received a knock on the head, followed by any serious symptoms, without fracture or depression, would escape the trephine, and the worst practice would be again established. An operation should never then be performed under the expectation that such an accident may have happened, unless it is apparently required by the urgency of the symptoms indicating compression or irritation of the brain, which cannot be relieved by other means.” — {On Injuries of the Head, ifc., p. 79.) GUNSHOT FRACTURES OF THE INNER TABLE OF THE SKULL. 157 number of illustrations have been cited, and it will be more profitable to examine the mechanism of this form of fracture, utterly misunderstood until a very recent period. For centuries it has been taught that this form of fracture took place because of the gi’eater brittleness of the inner table,' and this explanation was accepted by the leading surgical authorities until 1865, when the experimental inquiries of Mr. W. F. Teevan,^ ol London, proved that it was erroneous, and demonstrated that the cause of this fracture was not the brittleness of the vitreous plate, and was not to be sought for in any of the reasons heretofore assigned; but that it occurred in obedience to a well known physical law, viz.: That fracture always commences in the line of extension, not that of compression. It can be shown experimentally that violence applied to the inner surface of the skull may produce fracture of the external table only, without any lesion whatever of the inner, and there is at least one pathological specimen in existence illustrating this form of injury.'' This is conclusive proof that the brittleness and lesser superficies of the inner table has nothing to do with the causation of this form of fracture. Mr. Teevan’s explanation is undoubtedly the correct one. He aptly illustrates this variety of fracture by the familiar instance of the cracking of a thin sheet of ice under pressure. Fissures are often seen on the under surface of the ice and none on the upper, and always the crack commences on the under or distal surface. In bending a stick across the knee it begins to break at a point opposite to the spot where the knee is applied, the fracture commencing there in obedience to the physical law that when pressure is applied to a body it will first give way in the line of extension. The annexed diagrams, copied from Mr. Teevan’s paper, show the rationale of this form of fracture. As when a stick is bent, the atoms along the proximal curve at which pressure is made are brought near together or compressed, and the atoms along the distal curve * Broilie expressed the belief of the English surgeons : “ Tlie greater elasticity of the outer table of the skull, and the greater brittleness of the inner table, seem to afford the only reasonable solution of these phenomena.” {Med. Cliir. Trans. Vol. XIV, p. 331.) Vidal de Cassis, {Pathologie Ezterne, T. 11, p. 545,) gives the views of the modern French surgeons: “La table externe percutee, peut r6si&ter, tandis que la table interne se fracture imraddiatement au-dessous, parcequ’elle est plus cassante, aussi I’a-t-on appelee vitrde.” Velpeau, {Dc V Operation du Trepan, p. 29,) is of the same opinion: “Plus mince, inoins 6tendue en surface, plus irrdgulidre, plus dense que la table externe, la couche vitree 6clate et se fendille sous un effort manifestemont nioindre que la prdeedente.” Legouest, {op. cit. p. 283,) says: “Lorsque Tos frappe est epais, resistant et ft diploe solide, la table interne, plus mince et plus friable que I’externe, se rompt quelquefois, cette dernidre restant intacte.” The German surgeons had the same view of the causation of this fracture, as indicated in Professor Friedberg’s paper in Virchow’s Archiv. for 1851. B. Beck, {loc. cit.,) who performed many experiments on the dead subject, striking the skull with bullets, and often producing, by oblique impact, fracture of the innated, the tongue being somewhat coated. The intellect was unimpaired. He seemed to improve and was soon able to leave the ward, lie continued so for two or three days when he again took to his bed, com- plaining of slight pain in the head, but manifesting no aber- ration of mind. Coma and subsultus tendimun snjier- vened; discharge of blood and pus from the right, and pus only from the left, ear occurred, and death ensued on Juno 6th, , , ... Fio. 08. — Exterior view of the foregoiiip; specimen. 1804. At the autopsy a slight linear fissure of the frontal bone was observed, and on removing the calvaria a fracture of the internal plate and necrosis to the extent of three-fourths by one and a fourth inches was found to exist; including within its limits part of the posterior wall of both frontal sinuses, in which some half a drachm of pus had formed. The brain in the region of the fracture was softened. The adjoining wood-cuts (Figs. 07 .and 08) show the linear but slightly depressed fracture which e.xisted over the right superciliary ridge, and a portion of the fragment of the internal t. able which was detached. The frontal sinuses are unusu.ally capacious; the walls are very thin. The specimen and notes of the case were contributed by Assistant Surgeon J. C. McKee, U. S. A. Fig. 67. — Section of the frontal bone showin" a linear fracture over the right superciliaiy ridge. — Sjyec. 2492. Sect. I, A. M. M. Specimen 393 represents a dense, heavy and rather thin calvaria with a gunshot contusion near the right frontal eminence, and near it a linear fissure of both tables. But it apjiears quite probable that this fissure was produced in removing the skull cap, as not infrequently happens in using a cliisel as a lever after sawing the bone : Case. — Private II. S. L , Co. A, Sbth Massachusetts Volunteers, aged 21 years, was wounded at the battle of South Mountain, Maryland, September 14th, 1832, by a round musket ball on the right side of the frontal bone, .at a point about one and a half inches anterior to tlie coronal suture, producing apparently only a scalp wound. lie was conveyed to the Newton University Ffospital, Baltimore, on the 20th of the month. The wound looked healthy, and the p.atient was free from pain in his head. On the 25th, secondary hmmorrh.age occurred from a small branch of the temporal artery which was promptly arrested by division and the application of a compress for a few hours. The case progressed favorably until tbe 0th of October, when a state of low muttering delirium supervened. When spoken to the patient would become conscious for a few moments, but would immediately relapse into a comatose state, which continued until the 9th, when death resulted. At the autopsy the meninges gave evidence of a low degree of inllammation over a surface two inches in diameter. A few drops of pus were discovered upon the surface of the brain. The pathological specimen is No. 393, Sect. I, A. M. M. The frontal bone is con- tused one inch externally to the right of the frontal eminence with a fissure one inch in length running downward. There is a stellate fracture of the inner t.able with slight depression, the longest fissure being two inches in length. Two sm.all wart-like exostoses existed ne.ar the centre of the frontal bone, one on either side of the groove for the longitndimal sinus. The specimen and history were coutidbuted by Acting Assistiint Surgeon J. H. Cnrrey. Specimen 1951 shows linear fissures of the inner table beneath a necrosed portion of the outer plate, which appears to he slightly depressed. But it is difficult to decide whether this case should be referred to this category or to the one immediately preceding : Case. — Sergeant Ross D , Co. B, 19th Massachusetts Volunteers, was wounded in the engagement at Bristow Station, Virginia, October 14th, 1803, hy a conoidal ball which struck near and external to the left frontal eminence, slightly depressing the external and fissuring the internal table. He was admitted to the hospital of the 2d division. Second Army Corps, and on October 10th was sent to Lincoln Hospital, Washington. No cerebral symp- toms existed for some time after admission. On November 0th, hiemorrhage,- which was arrested by lig.ation, occurred from the .anterior tempoi’al artery. Hcemorrhage recurred on November 20th, and on the following day the wound beo.ame gangrenous. The patient grew comatose and died on November 29th, 1863. At tlie autopsy the external table was found necrosed, the diploe was filled with fungous gi-anul.ations. The dura mater was indurated beneath the injured spot, although no evidences of inflammation were present. On removing the brain a large quantity of thin pale serum was found in the snbar.achnoid space. A large abscess existed in tlie anterior of the left hemisphere just beneath the seat of injury, extending into the Lateral ventricle, filled with thick, sanious and ftt'tid jius. The right ventricle was normal. The pathologic.al specimen is figured in the cut (Fig. 09.) The inner t.able of the cranium presents a T-shaped fissure without depression, and is spongy. A thin plate of bone one inch in diameter is necrosed Fig. (fl. Ipicar fissure p the inner tabic of the on the external table, and the adjacent osseous tis.sue is porous and cribriform. The sjiecimen was contributed by Assistant Surgeon 11. Allen, U. S. A. GUNSHOT FKACTURES OF BOTH TABLES OF THE SKULL. 161 Gunshot Fractures of Both Tables of the Cranium Without Depression . — A number of instances of fractures of both tables of the skull were reported in which the evidences of injury to the bone were so slight that they were not recognized until after death. The following are good illustrations : Case. — Private William A- Co. F, 11th Pennsylvania Volunteer.s, aged 29 year.s, was wounded at the battle of the Wilderness, Virginia, May 7th, 1834, by a conoidal ball which struck the frontal bone between the eminences, laceratiir the muscles for about two inches and denuding the bone of periosteum for about one inch. The wound was con- sidered slight. The patient was treated for several days in a field hospital, and on May 11th was sent to the Lincoln Hospital, at Washington, whence, on May 18th, he was transferred to the Satterlee Hospital, Philadelphia. Cold water dressings were applied to the wound and the patient was able to be Fig. 71. — Interior view of the foregoing speci- men. Fig. 70. — Contusion and slight fracture of the frontal bone bj' a glancing musket ball. Spec. 2744, Sect. I, A. M. .M. about all the time. He was in good condition and appeared to do well until May 23d, when he became irritable, and complained of severe jiain in the head. The external wound still looked well. On the following day he became drowsy and suffered from nausea. The pain in the head continued unabated and the pulse was 110, but the mind clear. Small doses of creasote and- lime-water were given and he was freely purged. On May 24th the nausea subsided and the pulse had risen to 120; no pain in the he.ad, and the patient was rational though dull. On the25th the pulse was weak at 130, but the patient seemed perfectly conscious, and his mind was clear, and he declared that he felt perfectly easy, yet he died suddenly at five in the afternoon. This is the report of Acting Assistant Surgeon L. K. Baldwin, yet his ward case book states that the patient survived until the 26th, having low muttering delirium in the early part of that day. The autopsy was made forty hours after death by Acting Assistant Surgeon Charles P. Tutt. He reported that though the periosteum was removed the external table of the skull was scarcely injured, except by a shaving of lead from the ball firmly imbedded beneath the outer lamina at the inner upper margin of the wound in the periosteum. On removing the calvaria a large amount of piie was found upon the dura mater of the anterior lobe of the left hemisphere beneath the seat of injury. On removing the pus a spiculum of bone from the inner table was found to perforate the dura mater and a large abscess extending into the anterior horn of the left lateral ventricle was found beneath. A large eifusiou of serum was found at the base of the brain, and a yellow deposit was found on the pons Varolii and medulla oblongata and in the fissures of the cerebellum. A similar deposition of albuminous or puriform matter was also found under the arachnoid near the left ventricle. The viscera of the chest aiid abdomen were in a normal condition. The clinical history was furnished by Acting Assistant Surgeon L. K. Baldwin, who is also accredited with the specimen, of which an external and internal view is given in ■ the accompanying wood-cuts, (FiG. 70, and FiG. 71.) The notes of the autopsy were furnished by Acting Assistant Surgeon^ Tutt who made it. In the external table a portion of bone measui’ing one-fourth by one inch, a small fragment of which is depressed one line and surrounded by a slight groove, indicated an incipient exfoli.ation. At the uppei- inner portion of this oval groove a bit of lead is impacted. The inner table beneath is fissured for one inch beneath the seat of injury. Case. — Private George W. B , Co. A, 10th Pennsylvania Reserves, was wounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a canister shot which tore the scalp for an inch in extent over the left parietal bone, just behind the coronal suture. He was conveyed to Washington, D. C., and next day was admitted into the Stanton Hospital. The injury was regarded as slight, there being no evidence that the bone or structures beneath were seriously involved. With the exception of a slight headache, the case progressed well until the morning of the 22d, when he was seized with violent jiain in the head in the vicinity of the wound. He became restless and painfully sensitive to sound. On the evening of the 23d, and again on the morning of the 24th, chills supervened, attended with delirium. A few hours later insensibility of the l ight side of the body was noticed. A blister was applied over the nucha, and free purgations produced by cathartics. In the afternoon the patient was rational, and full sensibility in the body was restored. The chills being regarded of a malarious character, liberal doses of quinine were administered, and none occurred after the 25th of the month. On the 30th he fell into a semi-comatose state, and death ensued on the 4th of Janiuary, 1833, no convulsions having occurred at any time. The autopsy revealed a circular depression of the external table of tlie left jiarietal bone, just behind the coronal suture, half an inch in diameter, the surrounding bone being cribriform. The inner table was found irregularly fissured and depressed half aline. About an ounce and a half of a sanguine, purulent fiuid had collected between the dura mater and the cranium. The brain itself, however, appeared healthy. The pathological specimen is No. 628, Sect. I, A. M. M., and was contributed, with the history, by Surgeon .John A. Lidell, U. S. V. It is quite remarkable to observe that several of the fragments of the vitreous jilato are very firmly re-united, the patient having survived the injury only twenty-three days. A musket ball impinging obliquely upon the vault of the skull, will occasionally detach a portion of the calvaria, an inch or more in its diameter, without any depression of the margins of the solution of continuity thus produced in the cranial bones. A patient who 21 162 WOUNDS AND INJURIES OF THE HEAD presented a remarkable illustration of an injury of tins description is represented in the plate opposite. The history of the case is as follows : Case. — Private Edson D. Bemis, Co. K, 12th Massachusetts Volunteers, was wounded at Antietam by a musket ball which fractured the shaft of his left humerus. The fracture united kindly, with very sliglit angular displacement and quarter of an inch shortening. Promoted to be corporal, Bemis received. May 6th, 1864, at the battle of the Wilderness a wound from a musket ball in the right iliac fossa. He was treated in the Chester Hospital, near Philadelphia. There was extensive sloughing about the wound, but it ultimately healed entirely, leaving a large cicatrix, parallel with Poupart’s ligament. Eight months after the injury, Bemis returned to duty with his regiment. On February 5th, 1865, Corporal Bemis was again severely wounded at the engagement at HatcheFs Run, near Petersburg, Virginia. Surgeon A. Vanderveer, 66th New York Volunteers, reports that the ball entered a little outside of the left frontal protuberance, and passing backward and upward, removed a piece of the squamous portion of the temporal bone, with brain substance and membranes. When the patient entered the hospital of the 1st division of the Second Corps, brain matter was oozing from the wound. Thei'e was considerable haemorrhage, but not from any important vessel. Respiration was slow ; the pulse 40 ; the right side was paralyzed and there was total insensibility. On February 8th, the missile was removed from the substance of the left hemisphere, by Surgeon Vanderveer. It was a conoidal musket ball, badly battered. The patient’s condition at once improved. He told the surgeon his name, and seemed conscious of all that was going on about him. Water dressings were applied, and an ingeniously arranged sponge absorbed the discharge from the wound. He was kept on very light diet and remained very quiet for ten days, answering dii'ect questions, but indisposed to continue a conversation. He had no convulsions and his sleep was not disturbed by delirium. About February 18th, a marked improvement was manifest. The patient conversed freely, and the wound was rapidly cicatrizing, and the hemiplegia had entirely disappeared. On February ■28th he was able to walk about the ward. On March 18th the wound was nearly healed. The patient was sent northward on a hospital transport to Fort Richmond, New York Haihor. He recovered perfectly, and in May was furloughed, and on May 18th he wrote to Dr. Vandeveer, that he was doing well at his home in Huntington, Massachusetts, suffering only slight dizziness in going out in the hot sun. In July he went to Washington to apply for a pension, and entered Campbell Hospital. He was discharged on July 13th, 1835, on surgeon’s certificate of disability. At this date he was photographed at the Army Medical Museum. The wound in the head was then neaVly healed. There was a slight discharge of healthy pus from one point. The pulsations of the brain could be felt through the integument. The mental and sensory faculties were unimpaired. The corporal had been discharged from service and recommended for a pension. The plate opposite is a very accurate copy of the photograph, which is numbered 58 of the surgical series, A. M. M. Mr. Bemis was pensioned at eight dollars per month. On October GOth, 1870, he wrote to the editor of the surgical history from his home in Sufficld, Connecticut, as follows : “ I am still in the land of tlm living. My health is very good considering what I have passed through at Hatcher’s Run. My head aches some of the time. * * j am niarried and have one child, a little girl born last Christmas. My memory is affected, and I cannot hear as well as I could before I was wounded.” The five following cases were of a somewhat similar nature, though the ulterior results were less satisfactory : Case. — Private William B. Brock, Co. B, 110th Ohio Volunteers, aged 3’2 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket ball, which struck about two inches to the left of the median line and anterior to the coronal suture, passed backward along the sagittal suture, fracturing the external table of the left parietal bone, and emerged about two inches from the point of entrance. He was admitted to the hospital of the 3d division, Sixth Corps ; on June 7th, was sent to the Lincoln Hospital, at W^ashington ; on June 18th, was transferred to the Summit House Hospital, and on October 7th, to the Satterlee Hospital, Philad(!lphia. The wound had healed, but the patient was nervous and could not bear the heat of the sun ; the vision of the right eye was impaired, and the right arm was nearly useless. He was discharged on F'ebruary 9th, 1835, and pensioned. On September 24th, 1837, Pension Examiner W. S. Parker rejrorted that the wound, which, it seems, resulted in exposing a portion of the brain, was about a year in healing ; the patient is unable to bear exposure to the sun or heat, and suffers from vertigo. His disability is rated total and doubtful. Case.- — Private George W. Bowen, Co. E, 59th Illinois Volunteers, aged 21 years, was wounded during the siege of Nashville, December 9th, 1864, by a conoidal musket ball, which fractured the right parietal bone, carrying away a piece one inch and a half in length by nearly an inch in breadth. On the same day he was admitted to the hospital of the 3d division. Fourth Corps, and transferred as follows: On December 12th, to Hospital No. 13, Nashville; January 5th, 1865, to Jefferson Hospital, Indiana; and on March 22d, to the Marine Hospital, St. Louis, Missouri, where he was discharged from service on April 18th, 1885. His memory was much impaired, and his gait unsteady. He was pensioned, his disability being rated total and permanent. Case. — Private Henry Cook, Co. 6, 1st Ohio Volunteers, aged 23 years, was wounded at the battle of Eesaca, Georgia, May 15th, 1864, by a conoidal musket ball, which produced a limited fracture of the skull without known depression. He was admitted to the hospital of the 3d division. Fourth Corps, and on May 23d was conveyed to the field hospital at Chattanooga; thence was sent to the Cumberland Hospital, at Nashville, on May 26th. He was furloughed in August, with orders to report at the expiration of his leave to the Medical Director. On August 23d, 1834, he was discharged the service and pensioned. Pension Examiner C. J. Neff reported on February 22d, 1868, that a jjortion of the skull has been removed, leaving the brain exposed. There is partial loss of memory, constant headache, paralysis of superior extremities, subsultus, etc. He rates his disability as total and permanent; Med. a Surg. Hist . of the War of the Rebellion, Pait I. Vol.H. 0]«.pnjp 162. 1 ^<-5^" VCS^ ‘''' V / ^ t'- < r-i. Js- ' f '.'S.. ‘ ' mwm&\‘wm '1 2~- , . • ' .Nit'" ’ •‘■'1 «'-<% '.'i r '.5 ji,v'c' ■<'.*-\d t. ? t, r- ,^'aV'®''N f\ M '^^^ sv w '• f«i- /I'f's.'k >:vH „ wi;;v:''H>'''Vr . pr ,*"'# 'A-jJ'v?- i 5^5v,-vC' s. -t.^ >aj»tW '%!{S<#|£?I m^s i, ‘Ki^v 1V-W « ■.V-•^i v^I 2. wf Ni?-.- T Sinclair a- Sou ,iith Phila, PLATE V. SHOT WOUNDS OF EDSON D. BEMIS. ( See page 162.) GUNSHOT FRACTUEES OF BOTH TABLES OF THE SKULL. 163 Case. — Priv’ate Elias Hess, Co. C, 199th Pensylvania Volunteers, aged 18 years, was wounded in an engagement before Petersburg, Virginia, April 2d, 1365, by a conoidal musket ball, which fractured the right side of the frontal bone. He was admitted to the hospital of the Twenty-fourth Corps, and on April 5th, was sent to the hospital at Fort Jlonroe. Application of simple dressings constituted the treatment. On May 17th, he was transferred to the IVIcClellan Hospital, Philadelphia, and on July 10th, 1865, he was discharged the service. In July, 1868, he was a pensioner, his disability being rated one- third and permanent, by Dr. F. F. Burmeister, the pension examining surgeon. Case. — Corporal August Biihhneier, Co. B, 20th New York Volunteers, was wounded at Antietam September 17th, 1862. A portion of the frontal bone, let! side, had been fractured and partly torn away, leaving the brain exposed for a space of two inches by one inch. He was taken prisoner, afterward paroled, and on November 15th, was admitted to Hospital No. 1, Annapolis, whence he was discharged the service, March 13th, 1863, being unable to undergo either mental or physical exertion. He was pensioned, his disability being rated three-fourths and permanent, by Pension Examining Surgeons O’Meagher, Treadwell, and Fergusson. Similar lesions were produced by fractures from shell fragments : Case. — Private George W. Washabaiigh, Co. G, 100th Pennsylvania Volunteers, aged 22 years, was wounded at James Island, South Carolina, June 16th, 1862, by a fragment of shell, which fractured the superior border of the right parietal bone, carrying away an inch and a half in dimension, and lacerating the dura mater. The wound healed in four months, when violent convulsions, followed by insensibility, supervened. He was discharged October 9th, 1862, and pensioned. On September 3d, 1866, Pension Examiner J. P. Hosack reported that a portion of the skull, three inches in length by one in width, has been removed; that the patient sutfers from constant pain in the head, and from partial paralysis of one arm ; and that, when excited, he is subject to convulsions. His disability is rated total and, probably, permanent. Case. — Private William P. Dean, Co. D, 8th Pennsylvania Reserves, was admitted to Hospital at Upton’s Hill, Virginia, with a gunsliot fracture of the skull, caused by a fragment of shell. He was discharged the service March 7th, 1863, and pensioned. On February 3d, 1868, Pension Examiner F. C. Robinson reported that the patient has an opening through the skull at the vertex nearly one inch long and one-fourth of an inch wide, and that he complains of headache, vertigo, and dimness of vision, which were aggravated by hard labor or exposure to the vicissitudes of the weather. His disability is rated one-fourth and permanent. Examples will be given hereafter of the splitting of bullets upon the cranial bones. There are instances, however, which will more properly find a place here, in which a bit of lead is clipped off, and fissure with very trifling depression produced, as in the following case : Case. — Corporal William E. S , Co. F, 84th Pennsylvania Volunteers, aged 25 years, was struck at the battle of the Wilderness, May 5th, 1884, by a musket ball on the forehead, a little to the left of the median line. He was taken to the third division field hospital of the Second Corps, and was thence sent to City Point, and transferred on a hospital transport to Wash- ington, and on May 16th admitted to Mount Pleasant Hospital, Washington, D. C., and on May 27th sent to Chester Hospital, Pennsylvania. The wound was discharging sanious matter, and was much inflamed and painful. There was considerable fever, which increased on the 29th. On the following day the patient became delirious, and died on May 31st, 1864, from meningitis. The pathological specimen, which is represented in the adjoining wood-cuts, (Fig. 72 and FiG. 73,) consists of the body of the frontal bone, with a fragment of lead impacted near the centre and to the left of the median line. An ovoid plate of the external table, measur- ing one by two inches, is slightly discolored, and surrounded by a groove of demarcation, external to which the bone is cribriform. A plate of the inner table, measuring one square inch, is detached by three of its sides, and driven inward to the depth of two lines at its free edges. Two fissures, each one and a fourth inches in length, run back- ward and outward, and there is a slight deposit of new osseous materials on the inner surface, by Surgeon T. H. Bache, U. S. V. Fig. 72. — Exterior view of a frontal bone contiLsed by a bullet, and having a fragment of lead impacted under the outer lamina. Spec. 2523, Sect. I, A. M. M. Fio. 73. — Interior view of the preceding specimen, showing the depression of the vitreous table. The specimen was contributed The next two abstracts refer to very similar cases : Case. Private Allen Harrison, Co. L, 2d New York Mounted Rifles, aged 34 years, was wounded in an engagement before Petersburg, Virginia, July 8th, 1864, liy a conoidal musket ball, which struck the frontal bone in the upjter portion, causing two slight fissures, small portions of lead remaining imbedded in the outer table. He was admitttid to the hospital of the 2d division Ninth Corps, and on July 16th was sent to the Mower Hospital, Philadelphia. On .July 24th, a severe attack of acute pleuritis was followed by symptoms of hepatitis. His respiration Ix-came shoii and labor<>d, and the conjunctiva) and skin 164 WOUNDS AND INJUKIES OF THE HEAD tinged with yeljow; the tongue was dry and coated, and he complained of severe pain in the liver. A blister plaster was applied to the side of the chest, and squills and solution of morphia and stimulants prescribed; but he sank raj)idly and died on July 28th, 1854. Ui)on removing the calvaria at the autopsy, an abscess was found directly under the point of injury, over the longitudinal sinus, containing half an ounce of dark green offensive pus. Tlie dura mater was much thickened, but there was little evidence of congestion of the brain. The liver was pale. One pint of serum was found in each side of the pleural cavity. There had been inflammation of the lower lobe of the right lung. Symptoms of compression, if present, were so masked by |)leuritic and hepatic indications as to escape notice. Acting Assistant Surgeon W. F. Moon, reported the case from notes furnished by Dr. Fell, and subsequently published an abstract of it in an article on gunshot wounds of the head, in the American Journal of the Medical Sciences for July, 1836, and fuller data have heen derived from the hospital registers. Ca.se. — Private A. Stanton, Co. G, 1st New York Dragoons, received, at the battle of Winchester, Virginia, September 19tb, 1884, a gunshot wound of the head. The skull was fractured from the right orbital arch upward and inward about three inches. A bit of the conoidal musket ball which indicted the injury was chipped off by the outer table of the frontal. He was admitted to the Cavalry Corps hospital on the following day. The patient was at times partially conscious, and suffered from pain in the head and irritative fever. The functions of the body were normal, but he became very emaciated, sank gradually, and died, without convulsions, October ICth, 1834. Ill tlie following cases the ball lodged in the diploe or sinuses : Case. — Private Jacob Miller, Co. K, 9th Indi.ana Volunteers, aged 25 years, was wounded at the battle of Chickamauga, September 19tli, 1833, by a buck shot, which penetrated and lodged in the frontal bone near the nasal eminence, causing fracture of the left orbit and cxophthalmia of the eye. On the same day he was admitted to hospital No. 5 at Nashville, and on October 20th was transferred to No. 13, Louisville, whence he was transferred on the 25th to New Albany, Indiana, and thence on March 19th, 1834, to the hospital at Madison, Indiana. The missile was extracted on June 15th, 1864, and expectant treatment only was used. The patient, recovering, was transferred to Indianapolis Sejitember 2d, 1834, to be mustered out of serviee, and was discharged September 17th, 1834, and pensioned. On August 17th, 1868, Pension Examiner A. Coleman reports the patient suffering from caries of the frontal bone, attended with purulent discharge, loss of power in left eye, general disturbance of the mental faculties, which are aggravated when the wound discharges much, and at times complete pi’ostration. A subsequent report from Pension Examiner J. K. Bigelow, dated January 7th, 1870, confirms previous statement of patient’s condition, and rates his disability as total and permanent. Case. — Private Charles E , Co. K, 51st New York Volunteers, aged 22 years, was wounded, at the battle of New Berne, North Carolina, March 14th, 1862, by a conoidal musket ball, whicli struck obliquely above the right frontal sinus. The ball split upon the outer table, and the larger portion of it passed under the occipito-frontalis tendon, and the remainder was inqiaeted in the sinus. The patient was conveyed in an ambulance to New Berne, and entered the Academy Green Hospital. The portion of ball which lodged under the aponeurosis was extracted. Cold water dressings were applied, and the case was treated on the ex- pectant plan. Synq)toms of compression of the brain soon supervened ; yet the patient survived until October 25th, 1862. At the autopsy it was 75.-Interior view of the preceding specimen, found that there was an ab- scess of the brain, and that a fracture with depression passed through the right frontal sinus. The external opening measuring three-fourths of an inch in length, and one-third of an inch in width, with edges rounded by the commencing repair. One and a half square inches of the inner table are depressed half an inch. The fragment of ball which penetr.ated the frontal sinus projects slightly into the cranial cavity to the left of the longitudinal ridge of the os frontis. The specimen was sent to the Army Jledical Museum from New Berne, and is represented in the accompanying wood-cuts, (Fig. 74, and Fig. 75,) and was accredited to Surgeon C. A. Cowgill, U. S. V. ; but Dr. Cowgill verbally informs tiie editor that he has no recollection of the case or of the specimen. The specimen is a very interesting one, and was probably sent to the Surgeon Gener.al’s office by one of the assistants at the Academy Green Hospital, without the name of the donor, and only the brief memorandum, the chief points of which are recapitulated al)ove. Case. — Private John D. Clark, Co. I, 53d Ohio Volunteers, aged 18 years, was wounded near Eesaca, Georgi.a, May 25th, 1834, by a conoidal ball, which fractured the frontal bone above the right eye and lodged. On May 29th he was admitted to hospital at Chattanooga, Tennessee, .and was transferred as follows: on June 2d, to hospital No. 1, Nashville ; June 5th, to Joe Holt Hospital, Jeffersonville, Indiana; June 24th, to Camp Dennison, Ohio; .luly 15th, to Cleveland, Ohio ; August 10th, to Crittenden, Kentucky, and on October 7th, to Seminary Hospital, Columbus, Ohio. He was discharged December 13th, 1864, and pensioned. Subsequent information states that the patient is, at times, subject to spasms, and that there is partial paralysis of tne left side. His disability is rated one-half and permanent. C.VSE. Private Samuel H. McCartney, Co. K, 33th Illinois Volunteers, aged 22 years, was wounded at the battle of Pea Eidge, Arkansas, March 8th, 1832, hy a conoid.al musket hall, which struck the frontal bone about two IucIk's above the right Fig. 74 . — .Section of the frontal bone with a fragment of bali embedded in the frontal sinus. Spec. ,746, Sect. I, A. M. M. GUNSHOT FEACTUKES OF BOTH TABLES OF THE SKULL. 165 superciliary ridge, passing from the left to the right, crushing the hone at point of contact and lodged about one and a quarter inches from point of entrance. The dura mater was not injured. The wound healed in about four months, and on July 25th, 1862, he was discharged the service. On February 15th, 1836, Pension Exandner John Young reports that he was troubled with pain in the head at the point of injury, was subject to vertigo, and could not bear exposure to sun. His mind was also impaired. He is. not a pensioner. Case.— Sergeant J. A. Thompson, Co. E, 45th Georgia Eegiment, received a gunshot injury of the frontal sinus at the battle of the Wilderness, May 5th, 1864. On May 12th was admitted to hospital at Farmville, Virginia. There was a sanious discharge from the front.al sinus ; otherwise the case progressed favorably and the patient was allowed to go home on furlough. Case. Private Jacob Fisher, Co. D, 82d Ohio Volunteers, was wounded by a spent ball at the b.attle of Chancellorsville, Virginia, May 2d, 1863, which impinged upon the frontal bone above the left eminence, and produced a slight fracture. He was conveyed to the Harewood Hospital at Washington; on May 9th was sent to the McClellan Hospital, Philadelphia, and on July 6th, to the Sixteenth and Filbert Streets Hospital. No untoward symptoms are recorded, and the patient was returned to duty on July 7th, 1883 ; was discharged July 11th, 1833-, and pensioned, being subject to pain and vertigo. His disability is rated one-half, and perhaps permanent. Case.— Private Thomas M , Co. C, 4th New York Volunteers, was wounded near Antietam, Maryland, September 16th, 1862, bj’ a conoidal ball which fractured the mastoid portion of the left temporal bone. He remained in the field hospital until the 26th, when he was admitted into the Mount Pleasant Hospit.al, Washington, D. C. Phlegmonous erysipelas attacked the scalp, and the inflammatir>n extended to the membrane of the brain and death supervened on the 5th of October. The pathological specimen is represented in the adjacent wood-cut, (Fig. 76.) The injury of the outer table involves a little over one square inch of surface; that of the inner table measures one by one and a fourth inches, and includes the groove for the lateral sinus. Two fragments are attached, the free edge of one being depressed two lines. The fractured sur- faces are necrosed. The specimen and history were contributed by Assistant Surgeon C. A. McCall, U. S. A. Case. — Private Thomas P- -, Co. D, 30th Maine Volunteers, was, on Fig. 76. — Section of a cranium showing a gunshot . fracture of the mastoid process. Spec. 161, Sect. I, A. April 5th, 1865, admitted to the Jarvis Flospital, Baltimore, Maryland, with m. M. typhoid fever. He had partially recovered from fever, when he died on July 2d, 1865. The autopsy revealed an indented fracture of the frontiil bone, above and external to the right frontal eminence. The rim of depression was three-fourths of an inch in diameter, and the depth in the centre one-fourth of an inch. A portion of the outer table had been removed. The inner table was fractured in three triangular jilates, all of which were firmly consolidated, and all the fissures were filled up by a deposit of new bone; the depression of that table being two lines. The substance of the brain immediately under the injured bone was found softened and disorganized. The pathological specimen is No. 2619, A. M. M., and was contributed, with the history, by Assistant Surgeon D. C. Peters, U. S. A. Case. — Private D. L. Underwood, Co. D, 18th Georgia Regiment, received a gunshot wound of the head involving the frontal sinus. He was admitted into the Jackson Hospital, division No. 1, Richmond, February 17th, 1865. A fistula afterward formed. He was furloughed for sixty days. Ca.se. — Sergeant Augustus Reinwald, Co. G, 42d Pennsylvania Volunteers, was wounded at the battle of South Mountain, Maryland, September 14th, 1862, by a conoidal ball, which entered the .left side of the face at base of nose, passed backward, and emerged from behind the right ear, separating the mastoid process of the temporal bone. He became insensible. For several hours after return of consciousness there was bleeding from mouth, ear, and eye. On September 29th, he was admitted to the Patent Office Hospital, Washington, and on October 5th sent to Ladies’ Home Hospital, New York City. The portio dura and third pair of nerves were paralyzed. There was loss of vision of right eye, and of sensation and mobility of right side of face. The patient was unable to swallow or open his mouth. Febrile action set in, which, together with pain in head and jirofuse suppuration of wound, rapidly reduced the strength of the patient. He became pale, weak, and emaciated ; skin was moist, appetite poor ; pulse regular, slow, and compressible ; the eye was lachrymose, and the mouth drawn to ofiposite side. The wound inThe face healed, but the posterior wound continued to discharge profusely. He was discharged oh March 21st, 1863, and pensioned, his disability being rated one-half, by Surgeon A. B. Molt, U. S. Vols. In many of the cases classified under the head of gunshot fractures of both tables of the skull without known depression, the details of the symptoms and treatment are very meagre, and it is impracticable to verify the diagnoses from the evidence presented in the reports. The following series fairly illustrates this class of cases, in which the instances of recovery and pension largely predominated : Case. — Lieutenant .John Adams, Co. G, 35th Ohio Volunteers, aged 30 yiuir.s, was wounded at Chickamauga, Seiifember 19th, 1863, by a conoidal musket ball, which fractured the upper jiortiou of the right side of the frontal bone; he also received a 166 WOUNDS AND INJUKIES OF THE HEAD, gunshot wound of the liand. Treated at the hospital of the 3d division, Ninth Corps, the hospital at Stevenson, Alabama, the officers’, hospital at Nashville, and the general hospital at Covington, Kentucky, where he arrived May 26th, 1864, and was discharged June 3d, 1864. In September, 1867, *he was a pensioner, his disability being rated tliree-fourths and permanent. Ca.se. — Captain K. P. Andis, Co. B, 99ih Indiana Volunteers, aged 34 years, was wounded near Atlanta, Georgia, July 21st, 1834, by a conoidal musket ball, which fractured the left temporal bone. Treated at hospital of the 4th division, Fifteenth Corps, until August 13th, when he was sent north ; admitted to Grant Officers’ Hospital, near Cincinnati, December 20th ; was discharged the service December 30th, 1864, by special order of the War Department. In July, 1838, he was a pensioner, his disability being rated two-thirds and temporary. Case. — Sergeant Stephen Aldrich, Co. E, 141st New York Volunteers, aged 26 years. F'racture of the occipital bone by a conoidal musket ball. Dallas, Georgia, May 25th, 1864. Treated at the hospital of the 1st division. Twentieth Corps, the field hospital at Chattanooga, the Sherman Hospital at Nashville, and the hospitals at Jeffersonville and Elmira. Discharged fi om service February 27th, 1865. In March, 1868, he was a pensioner, his disability being rated one-half and temporary. Case. — Private George H. Barlow, Battery K, 14th New York Artillery, aged 26 years. Fracture of the frontal bone above the right eye, by a conoidal musket ball. Petersburg, June 17th, 1864. Treated at the regimental hospital. Mount Pleasant, Chester, and, after several transfers, at Carver Hospital. Discharged from service May 29th, 1865, and pensioned, his disability being rated total. Case. — Private Charles H. Barrett, Battery G, 2d Massachusetts Heavy Artillery, aged 25 years. Fracture of the right side of the cranium by a piece of shell. Plymouth, North Carolina, April 8th, 1864. Taken prisoner. Exchanged December 5th, 1884, and was treated in No. 1 hospital, Annapolis, and Dale Hospital, Worcester, Massachusetts. Discharged from service July 7th, 1865. In July, 1868, he was a pensioner, his disability being rated total and temporary. Case. — Piivate C. F. Benton, Co E, 116th Illinois Volunteers, aged 23 years. Fracture left side of frontal bone by a piece of shell. Jonesboro’, Georgia, August 31st, 1864. He was admitted to the hospital of the 2d division. Fifteenth Corps, where simple dressings were applied ; on September 5th, was sent to the hospital of the Fifteenth Corps, and on November 30th, to Camp Butler, Illinois. Discharged fi-om service April 8th, 1865. In July, 1868, he was a pensioner, his disability being I'ated total and permanent. Case. — Private Henry A. Bliss, Co. I, 18th Massachusetts Volunteers. Fracture of the temporal, malar, and superior and inferior maxillary bones, right side, by a conoidal musket ball. Cold Harbor, Virginia, June 1st, 1864. Treated in the Fifth Corps, 1st Division, Alexandria, De Cam'p, and Dale hospitals. Discharged May 9th, 1865. Not a pensioner. Case. — Private Jacob Burnes, Co. K, 100th Pennsylvania Volunteers, aged 27 year’s, was wounded at Fort Steadman, before Petersburg, March 25th, 1865, by a fragment of shell, which entered anterior to junction of coronal and sagittal sutures, fracturing the skull to the extent of three-fourths of an inch, but not detaching the bone. Fie was admitted to Carver Hospital, Washington, on April 5th, 1865, and was transferred, on April 9th, to Mower Hospital, Philadelphia, where he was discharged from service on May 29th, 1865, with every prospect of entire recovery. Is not a pensioner. Case. — Private Peter Campbell, Co. C, 81st Pennsylvania Volunteers, aged 17 years, was wounded at Hatcher’s Kun, Virginia, March 25th, 1865, by a conoidal musket ball, which struck the skull near the junction of the sagittal and lambdoid sutures, carrying away portions of hone. Treated in the hospital of the 1st division. Second Corps, and at the Armory Square, White Hall, McClellan, and Mower hospitals. Discharged from service July 31, 1865. Not a pensioner. Case. — Private J. A. Dietz, Co. G, 3d New York Volunteers, aged 24 years. Fracture of cranium and wound of shoulder, by a twelve-pound shot. Drurj^’s Bluff, Virginia, May 16th, 1864. Treated in the hospital of the 1st division. Tenth Corps, and at Mower, De Camp, and Ira Harris hospitals. Discharged June 15th, 1865, “able to earn partial subsistence.” Case. — Privmte Thomas Johnson, Co. G, 146th New York Volunteers, aged 42 years. Fracture and loss of a portion of the occipital bone by a piece of shell. Petersburg, June 24th, 1864. Treated at division, Alexandria, Carver, and Ira Harris hospitals. Discharged from service May 4th, 1865, and pensioned, his disability being rated one-half. At the latter date, his limbs and faculties were normal, but his strength was impaired, and he was only able to earn partial subsistence. Case. — Private Augustus Juno, Co. G, 147th New York Volunteers, aged 40 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1834, by a conoidal ball, which fractured the cranium. On the same day he was admitted to the hospital of the 4th division, Ffifth Corps. The injury was considered slight, and, apparently, caused little or no inconvenience, as the man served with his regiment again until February 1st, 1865, when he was admitted to the Fifth Corps hospital at City Point. On February 14th, he was sent to the hospital at Point Lookout, Maryland, where he remained until June 10th, 1865, when he was discharged the service. In July, 1888, he was a pensioner, his disability being rated at one-half and temporary. His pension was increased on March 21st, 1870. Case. — Private James Landon, Co. K, 179th New York Volunteers, aged 19 years. Fk-acture of the frontal bone by a conoidal musket ball. Petersburg, April 2d, 1885. Treated, by the application of simple dressings, at division, Slough, and Mower hospitals. Discharged from service June 22d, 1865, and pensioned. Pension Examiner J. G. Orton, in a communi- cation dated June 29th, 1865, stated that the wound was still discharging, but that the patient would probably improve. In July, 1868, his disability was rated total and permanent. Case. — Private William Meyers, Co. A, 7th Iowa Volunteers, aged 39 years. F’racture of tlie frontal bone by a conoidal musket ball. Kesaca, Georgia, May 15th, 1864. Treated at the hospital at Chattanooga, the No. 1 hospital at Nashville, and the hospitals at Mound City and Davenport. Throughout treatment, the patient suffered from ulcers on v.arious parts of his body, sujiposed to have been caused by vaccination. Discharged June 21st, 186.5, and j)ensioned, his disability being rated one- tliiid. There was impairment of cerebral functions. DEPRESSED GUNSHOT FRACTURES OF BOTH TABLES OF THE SKULL. 167 Case. — Private Edward B. Ockington, Co. G, 37tli Massachusetts Volunteers, aged 28 years, was wounded at Winches- ter, Virginia, September 19th, 1864, by a fragment of shell, which produced a stellate fracture of the frontal bone. He was treated at corps, Sandy Hook, and McClellan hospitals. The patient had nearly recovered in December, and was sent to Camp Distribution, Virginia, but he was returned to the Carver Hospital at Washington, on December 16th, and on March 13th, 1865, was transferred to Dale Hospital, Massachusetts, where he was discharged the service on May 24th, 1835. Not a pensioner. Case. — Private Owen F. Prentice, Co. C, 35th Illinois Volunteers, aged 32 years. Fracture of the frontal bone above the left eye, by a conoidal musket ball. Chattanooga, November 8th, 1863. He was admitted to the Cumberland Hospital at Nash- ville, on December 9th, and furloughed on the 23d. On April 26th, 1864, he was admitted to the Camp Butler Hospital, Illinois. The wound, at this time, was doing well, but the patient was unable to undergo any active exertion. He was discharged from service June 9th, 1864, on account of total disability. Not a pensioner. Case. — Private Johir Spurrier, Co. A, 142d New York Volunteers, aged 22 years, was wounded in an engagement on the Darbytown Road, Virginia, October 26th, 1864, by a conoidal musket ball, which fractured a portion of the parietal bone. On October 29th, he was admitted to the Balfour Hospital, Portsmouth, Virginia, where he remained under treatment until March 10th, 1865, when he was admitted to the Grant Hospital, New York Harbor. At this time the conjunctiva was inflamed. He improved; was, on April 4th, sent to Rochester, New York, on July 6th, to the Ira Harris Hospital, Albany, New York, and on August 4th, 1865, was discharged the service. Not a pensioner. Gunshot Fractures of Both Tables of the Cranium with Depression . — I shall now adduce illustrations of the principal varieties of depressed gunshot fracture of the skull. The oblique impact of musket balls upon the vault of the cranium sometimes produces a linear fissure of the outer table, with extended depression or displacement of the vitreous table. This form of accident is more likely to occur in a young subject, and upon those portions of the skull well supplied with diploe. Specimens of this injury are not very common. It would be difficult to select a better illustration than is afforded by the following case : Case. — Private If. L. H — , Co. E, 21st Virginia Regiment, aged 20 years, was wounded at Petersburg, Virginia, in the assault on Fort Steadman, March 25th, 1865, l)y a musket ball which struck the forehead. He was made a prisoner and admitted to the hospital of the Ninth Army Corps at City Point. On March 27th he was conveyed in the hospital transport steamer “ State of Maine ” to Washington, and placed in the Lincoln Hospital on March 28th, with a wound over the left supra-orbital ridge, apparently inflicted by a glancing musket ball. There were no cerebral symptoms when the patient w^as admitted, and he seemed to be doing well for several days, being quite free from pain or any febrile movement. The pulse was normal and the howels in good condition. On April 1st, he complained of a dull deep-seated pain over the left eye. Later in the day he was feverish and restless, his countenance was pale, and his pulse slow and weak. On April 2d, he failed rapidly. On the night of the 3d, he was delirious. On the 4th, there was violent raving, which continued until his death, on the afternoon of April 5th, 1865. At the post-mortem examination, a fissure was found extending into the right orbit, and upward beyond the left frontal prominence. The vitreous table beneath was largely depressed. There was a small abscess in the anterior lobe of the left cerebral hemisphere. The specimen was contributed by Acting Assistant Surgeon J. P. Arthur, and is represented in the accompanying wood-cuts, (Fig. 77 and Fig. 78.) Two fragments of the inner table are driven inward to the depth of half an inch, touching each other by their inner edges like the leaves of a folding door just ajar. (See Catalogue Surg. Sect. A. M. M., page 10.) Fig. 77. — Section of the frontal bone, exhibiting a fissure over the left supra orbital region. — Spec. 2-4, A. M. M. Fin. 78. — Intomnl view of the foregoing specimen, showing the c.\tensivc splintcringoftlic vitreous table. The examples of slight depression of the external table with great depression internally were, of course, very numerous. It is necessary to cite but few : Case. — I’rivate George V , Co. CV 84th New York Volunteers, was wounded at Chancellorsville, May 3d, 1863, and admitted into Carver Hospital at Waslungton, D. C., on May 7th, 1863. His injury was supposed to bo a sinqilo scalp wound from a musket ball. It was situated over the right parietal protuberance, and on admi.ssion was granulating kindly. Ten days subsequently the patient, after a walk out of doors and sitting in the hot sijn, had htiadache and nausea, and the wound gaped and its edges ulceratetl. On May 17th there was headache, and his stomach would not retain food. On May 168 WOUNDS AND INJUEIES OF THE HEAD, 18tli tlie probe detected denuded bone; but no fracture was discovered. There were no fel)rile or cerebral symptoms. On May 20tli a depression of the outer table of the skull was detected. At night there was delirium, and the following day the pulse b(?came feeble and irregular, the stomach irritable, the tongue heavily furred. On this and the following nights the patient had two and a half grains of opium at bedtime. His diet was low, though chicken broth and custard were allowed. On this day there was a decided icteric hue over the whole surface. The patient died on May 22d, 1863, being conscious and rational to the last. At the autopsy, extensive inflammation of the dura mater was observed, and softening of the middle lobe of the right cerebral hemisphere. The notes of the case were drawn up by Assistant Surgeon I'l. F. Bates, U. S. V., and were contributed with the specimen, which is represented in the wood-cuts .above, (Fig. 79 and FiG. 80,) by Surgeon O. A. Judson, U. S.V. parictal~bon?'”l,^j)cc. I'gST^A *M *jT The fracture of the external table is half an inch Fio. 80. — Interior view of the foregoing in diameter, and is depressed two lines. The inner table is fractured to the diameter of an inch, and depressed in the centre one line. A few hairs are wedged in among the frag- ments. The surrounding bone is porous and cribriform. The classical “punctured” fracture of authors was not infrequently observed, and the Army Medical Museum possesses many specimens of this form of injury, one of the best of which is figured below : Fig. 81. — Fracture of the fnintui bone by a pistol ball. Spec. 1673, A. M. M. Case. — Private James K , Co. G, 6th New York Cavalry, was wounded at the battle of Gettyshurg, July 3d, 1863, by a pistol ball, which produced a punctured fracture of the os fronth. He was conveyed to a hospital at Baltimore, and from thence to Carver Hospital, at Wash- ington, on July 24th. He stated that, at Baltimore, he walked about and felt no inconvenience from his wound. On July 27th, he had a con- vulsion. The wound, whicJi was nearly healed, was laid open, and de- pressed bone being detected, an etfort was made to elevate it. Several small necrosed fragments were removed, and a small quantity of fetid pus escaped. The patient had become comatose, and the operation had no influence in relieving the symptoms. Death took place a few hours subsequently. At the autopsy, the extended depression of the inner table was discovered, and a large abscess of the brain. Fig. 82. — Interi.)!- view uf the foregoing specimen. Another common form is illustrated in the following case : Case. — Private Leonard L , Co. F, 74th New York Volunteers, was wounded at the battle of Williamsburg, May 5th, 1862, and was admitted into Broad and Cherry streets Hospital at Philadelphia, May 13th, 1862. A musket ball bad struck near the left parietal eminence, and producing a slight depression of the outer table, had lodged under the scalp, whence it had been removed by a surgeon on the field. The wound had a healthy aspect when the man was admitted, and there was no cerebral disorder. This favorable condition continued unaltered till !May 20tb, when a febrile movement set in, accompanied by nausea and vomiting ; drowsiness and stupor followed, and the patient died comatose on May 23d, eighteen days after the injury. At the autopsy a small clot was found bimeath the depressed jiortion of the vitreous plate; the dura mater was uuinjured; the arachnoid Fig. 82.— Pertinn of left p.ariot.al, show- near the seat of injury was opaque and studded with Fin- 84.— Interior view of the fore- itjff II sliffhtlv depressed fracture of the , • /. i i ‘ i* r. i -i • spechnon, oxhibitlnff extensive outer table. Spec. 224, A. deposits of lymph; tlie gray matter of the hrain was splintering of the vitreous table. softened. The external fracture w:is found to be circuhir and a half inch in diameter, a small fragment being driven in on the diploe. The internal table was more extensively fractured, and a plate of hone three-fourths of an inch in diameter was driven inward to the depth of two lines. The specimen, which is well represented in the foregoing wood-cuts, (FiG. 83 and Fig. 84,) was presented to the Army Medical Mnseuin by Acting Assistant Surgeon John Neill. It mi obably permanent. 176 WOUNDS AND INJURIES OE THE HEAD Cask. — Sergeant James R. Slonisou, Co. K, 13th Ne\v Hampshire Volunteers, aged 24 years, was wounded before Petersburg, June 23d, 1864, by a fragment of shell, which fractured a portion of the left parietal bone. He was admitted to the hosjiital of the Eighteenth Corps; thence he was transferred as follows: on the 25th, to the Chesape.ake Hospital at Fort Monroe; on .Inly 4th, by steamer, to Sixteenth and Filbert Streets Hospital, Philadelphia; .and on January 24th, 1865, to the Webster Hospital in New Hampshire. Paralysis of the right arm and h.and had supervened. He was discharged the service May 27th, 1865, and pensioned, his disability being rated one-half and permanent. Case. — Sergeant Slade Wooten, Co. C, 27th North Carolina Eegiment, aged 24 years, received, in an engagement near Petersburg, Virginiti, August 15th, 1864, a giuishot fracture of the left parietal bone severing the longitudinal sinus. He was retired on January 20th, 1865, by an examining board. The patient afterward suffered from partial paralysis of the left side accompanied by intense headache, and was unable to undergo any exertion without producing mental confusion. The following cases of gunshot depressed fractures of the cranial bones were followed by epilepsy : Case. — Priv.ate John Oxspring, Co. G, 109th Pennsylvania Volunteers, aged 36 years, was wounded at the battle of Ch.anccllorsville, Virginia, M.ay 1st, 1883, by a conoid.al musket ball, which fr.actured the frontal bone between the eminences, ‘probably causing a depression of the inner table. He was conveyed to Washington, and on the 0th was admitted into Lincoln Hospital, where the wound was properly dressed. Frequent epileptic convulsions ensued after a time. In July he was transferred to the Cuyler Hospital, near Philadelphi.a, where he continued under treatment until the 24th of March, 1804, when he was transferred to the Turner’s Lane Hospit.al. The convulsions continuing, resort was now had to the introduction of an issue pea in the hack of the neck, which, however, failed to alibrd relief, and was soon withdrawn on account of a severe attack of erysipelas following. On May 19th, 1804, he was discharged from service. In January, 1868, his disability was rated as three-fourths and permanent. The case is reported by Acting Assistant Surgeon W. W. Keen, jr. Ca.se. — Sergeant John tlaley, Co. C, 57th M.assachusetts Volunteers, aged 36 years, was wounded in the head at the b.attle of the Wilderness, Virginia, Maj' Gth, 1864, by a conoidal musket ball. He was sent to Washington on the IGth, and was admitted into the Lincoln Hospital, where no frain in side of head, and the principal discharge came from the external meatus, where a piece of bone made its exit. On August 22d, the orifice of entrance was filled with granulations, .and that of exit had become covered with jdastic lymph. The movement of jaw became, to some extent, limited, and the patient could not close the right eyelid or raise the right eyebrow. On May 31st, 1864, he was admitted to Fairfax Seminary Hospital; on June 7th, was sent to Had- dington Hospit.al, Philadelphia; on June 11th, to Satterlee Hospital; and on August 5th, to St. Mary’s Hospital, Detroit, Michigan, where he was discharged from the service September 13th, 1864. He is not a pensioner. Case. — Corporal James W. Williams, Co. G, 39th United States Colored Troops, aged 26 yeai’s, was wounded before Petersburg, Virginia, Jidy 30th, 1864, by a conoidal musket ball, which fractui-ed the frontal bone over tlie front.al sinus, near the parietal bone. No record of the case c.an be found until August 18lh, when the patient w.as admitted to the Summit House Hospital, Philadelphia. Pie was thence transferred as follows: on March 29th, 1865, to the hospital at Beverly, New Jersey; on May 12th, to the Whitehall Hospital, near Bristol, Pennsylvania; on June 26th, to the Satterlee Hospital, Philadelphia; and on July 30th, to the Mower Hospital, where he was discharged from service on September 9th, 1835, and pensioned. Subsequent information states that discharges of bone continued a year after the reception of the injury. The patient suffered from dizziness, faintness, and a sense of insecurity, which unfitted him for any occupation, especially such as required stoo])ing or exertion. His disability is rated one-half and temporary by Examining Surgeon J. li. Eowand. Flo. 99.— Exfi'liation from the right parietal and temporal, resulting from gunshot injury. Spec. ;i45i, A. M. M. EEMOTE RESULTS OF DEPRESSED GUNSHOT FRACTURES. 189 Case. — Sergeant John O’Flaherty, Co. D, 24th Wisconsin Volunteers, was wounded by a missile at the battle of Chick- amauga, Georgia, September 19th, 18G3, which fractured both tables of the frontal bone above the right eminence, lie was admitted to the field hospital, 3d division. Twentieth Corps, and on October 21st was sent to the hospital at Stevenson, Alabama. A day later, the patient was transferred to Hospital No. 13, Nashville. About December 1st, he was sent to Hospital No. 3, at Louisville, and on March 19th to the hospital at Madison, Indiana. He was discharged from service on April 19th, 18G4, and pensioned^ An opening, one inch and a half long by one inch wide, caused by exfoliation of bone, had healed and was covered only by the integument. The patient was subject to occasional attacks of vertigo following either mental or physical excite- ment, and loud voices produced pain in the head. His disability is rated three-fourths and doubtful. Case. — Private Charles E. Tremain, Co. II, 45th Pennsylvania Volunteers, aged 29 years, was wounded before Peters- burg, April 2d, 18G5, by a conoidal musket ball, wliich struck behind the right ear, fractured the occipital bone, and was afterward extracted from the neck. In the same engagement, and while in a state of unconsciousness, a ball struck the right foot on its outer edge, near the middle, and, passing inward and upward, emerged at the instep; the second toe of the same foot had been carried away by a rifle ball at the Wilderness, May 6th, 1864. He was treated at the depot field hospital of the Ninth Corps until April 7th, when he was sent to the Slough Hospital at Alexandria. The metatarsal bones became necrosed. He was mustered out July 17th, 1835, and pensioned from that date. On January 17th, 1870, Pension Examiner F. R. Wagner reports that the wound in the head often inflames and suppurates, and that dead ])ieces of bone exfoliate. The patient was subject to pain in the head, and his memory was greatly impaired. The foot was anchylosed and cold. His disability is rated total and permanent. Remote Results of Depressed Fractures . — Besides epilepsy and derangements of vision and hearing, and the other disabilities referred to on page 171 and the following pages, a large number of instances were reported in which gunshot depressed fractures of the skull were followed by headache and vertigo, persistent pain at the part struck, various forms of paralysis of motion, and modifications of sensation, and mental derangements. A few such cases may be cited : Case. — Private William H. Cash, Mcltitosh’s Battalion, Rockbridge Artillery, was wounded at Fredericksburg, December 13th, 18G2, by a fragment of shell, which struck the upper portion of the left side of the frontal hone, carrying away a segment of hone an inch square, and exposing the brain. He was admitted to hos{)ital No. 1, at Richmond, on January 26th, and, on March 13th, 1865, he was retired from the service. The cicatrix was at that time large, and the pulsations of the brain were plainly visible. Paralysis agitans, in an incipient form, existed at the date at which the patient was retired. The ulterior history of the case is unknown. The abstract is from the records of the Confederate Surgeon General's Office. Case. — Private Isaac P. Baldwin, Co. I, 41st Ohio Volunteers, aged 24 years, was wounded at the battle of Shiloh, Tennessee, April 7th, 1862, hy a missile which passed through the right malar and temporal bones. The case progressed finely. He was treated at City Hospital, St. Louis, and at Camp Dennison, Ohio. At the latter, on August 14th, 1862, he was discharged the service. He re-enlisted July 18th, 1863, and on January ISth, 1865, was again discharged, and was pensioned. In IMay, 1865, there was ptirtial paralysis of the left side of face, and deafness of the right ear, dnd his disability was rated one-half and permanent. Case. — Private Samuel Lyon, Co. E, 54th Now York Volunteers, aged 25 years, was admitted, on January 14th, 1863, to Mower Ho.spital, Philadelphia, with a gunshot fracture of the left parietal bone. The wound healed readily, and on !March 27th, 1863, he was discharged the service, being still troubled with neuralgic pains in the frontal region. He is not a pensioner. Ca.se. — Private Robert McAllister, Co. G, 57th New York Volunteers, aged 42 years, was struck by a bullet at Fred- ericksburg, December 13th, 1862, which caused a lacerated wound of the scalp, and fractured a poition of the left parietal bone. .He was admitted to the field hospital of the 1st division. Second Corps, on the same day, and a few days later was transferred to Washington, and on the 17th was admitted to the Campbell Hospital. On February 3d, 1863, he was discharged the service and pensioned, his disability being rated total and permanent. The case is reported by Surgeon J . H. Baxter, U. S. V. A subsequent report states the patient’s right arm to be paralyzed and atrophied. Case. — Private Henry Rice, Co. B, 29th Pennsylvania Volunteers, aged 27 years, was wounded at the battle of Altoona, Georgi.a, June 15th, 1864, by a conoidal musket ball which fractured the cranium. He was admitted to the hospital of the 2d division. Twentieth Corps, and on the 22d was sent to the general hospital at Chattanooga, Tennessee. On .July 7th ho was ti’ansferred to Nashville and admitted into hospital No. 19, but, three days afterward, was sent to .lefferson Hospital in Indiana. In September he was furloughed, and on the 1st of December transferred to the hospital at Madison. Partial paralysis of the body had ensued, and the patient was discharged the service December 2d, 1864. In Sejitember, 1867, he was a pensioner, his disability being rated total and perm.anent by Dr. J. Cummiskey, theqjension examiner. At that date paralysis was limited to the right foot. Case. — Private A. Perherson, Co. A, 13th Virginia Cavalry, was wounded at the battle of Gettysburg, .July, 1833, by a piece of shell which struck the skull at the vertex. His history is unknown until March 3d, 1864, when he was ailmitted to an hospital at Richmond, lie had been troubled with incontinence of urine ever since the reception of the injury. The wouiul had entirely healed, with slight loss of bone, showing a small furrow. The patient complained of severe pain in the lumbar region, and his speech indicated partial p.aralysis of the tongue. He stated that his right side had been ])artially paralyzed, and he still suffered occasionally from numbness of the right hand and foot. Oil of tuiqientine was ordered as a counter-irritant to the back, but up to May 23d, 1834, there had been no material change in the condition of the patiemt. 190 WOUNDS AND INJUEIES OF THE HEAD, Cask.— Private Augustus J. Duller, Co. A, 7tli Maine Volunteers, aged 1!) years, was wounded at tlie battle of Cold Harbor, Virginia, .June Ctb, ISG-l, by a conoidal musket ball, wbicb fractured the parietal bone at the eminence. He was conveyed by steamer to Aiexandiia, and admitted, on the 14tb, into the 3d division hospital. Paralysis of the lower extremities existed. Simple dressings only were applied. The patient recovered partial control of the muscles of the leg, and was discharged from service January 10th, 1865. Not a pensioner. Case. — Pilvate John Shoemaker, Co. H, 100th Illinois Volunteers, aged 19 years, was wounded near Hillsboro', Tennessee, August 1st, 1803, by a musket ball, which entered the vertical jiortion of the frontal and escaped at the centre of tlie right parietal bone, grooving both tables. For two weeks he was treated in the field hospital. On the 18th he was sent to the Cumberland Hospital at Nashville. On the 26th of September he was transferred to Louisville, Kentucky; thence, on the 2d of December, to the hospital at Quincy, Illinois. Partial paralysis of the left upper and lower extremities had ensued by this time, but the wound was gradually healing, and his appetite was good. By the use of strychnia, some improvement in the motion of the leg was obtained. He was discharged from service April 2d, 1864, still experiencing considerable difficulty in walking. Acting Assistant Surgeon D. C. Owen reports the case. Not a pensioner. Case. — Private Frederick Abel, Troop B, 5th New York Cavalry, aged 52 years, was wounded at the battle of White Oak Swam)), Virginia, June 15th, 1884, by a conoidal musket ball, which fractured and passed through the most prominent portion of the occipital bone. He fell to the ground insensible, and remained so for twenty-four hours. lie was then conveyed to the Chesapeake Hospital at Hampton. Paralysis agitans supervened immediately on return to consciousness. By the 4th of July he was able to bear transportation to the Sixteenth and Filbert Streets hospital in Philadelphia. On March 25th, 1885, he was transferred to the Turner’s Lane PIos))ital; thence, on May 10th, to the McClellan Ilosjsital, where he was discharged on July 1st, 1865. In January, 1888, he was in receipt of a pension, his disability being rated one-half and permanent. Case. — Private Christopher C. Colson, Co. A, 37th Massachusetts Volunteers, aged 24 years, was wounded at the battle of the Wilderness, Virginia, May Gth, 1864, by a conoidal musket ball, which fractured the left parietal bone. He was admitted to the hospital of the 2d division. Sixth Corps ; and thence, on the 25th, he was sent to the Armory Square Hospital at Washington. The case progressed well under ordinary treatment. On June 16th he was transferred to the Knight Hospital, New Haven, Connecticut ; on October 16th, to Eeadvillo, Massachusetts ; and on Slarch 22d, 1865, he was returned to duty from the Dale llosj)ital, Worcester, Massachusetts. Persistent hemicrania of the left side, however, rendered him unfit for duty, and, on May 23d, 1865, he entered the Lincoln Hospital, at Washington, and was mustered out of service June 12th, 1865. Case. — Private Jason Cowles, Co. E, 179th New York Volunteers, aged 43 years, was wounded before Petersburg, Virginia, April 2d, 1865, by a conoidal musket ball, which fractured the superior portion of the left parietal bone. He was admitted to the hospital of the 2d division. Ninth Corps, on Ai)ril 3d; was transferred to the hospital at Fort Monroe, and on June 29th sent to the Ira Harris Hospital, Albany, New York, where he was discharged from service on July 24th, 1865. On September 9th, 1867, Pension Examiner L. H. Allen reported a deep depression from loss of bone, which caused gi-eat physical and mental impairment. His disability was rated three-fourths and of uncertain duration. C.\SE. — Private Charles 11. Rhodes, Co. F, 3d Vermont Volunteers, aged 24 years, received a gunshot fracture of the skull at the battle of Fredericksburg, December 13th, 1862. He was admitted to the regimental hospital. On December 17th he was sent to St. Aloysius Hospital, Washington ; oil January 7th, 1863, was transferred to Governor Smith Hospital, Brattleboro’, Vermont, and was discharged the service January 31st, 1833, and pensioned, his disability being rated total. Case.— Private John E. Edmonds, Battery E, 2d New York Heavy Artillery, aged 22 years, was wounded at the battle of Petersburg, Virginia, June 18th, 1864, by a conoidal ball, which fractured the right parietal bone. He was admitted on the same day, to the 1st division. Second Corps, hospital, and was transferred to the Carver Hospital, Washington, on June 22d. The functions of the brain were found to be, in a measure, impaired. He remained in the Carver Hospital until October 25th, when he was transferred to the Kicord Hos))ital. Being regarded unfit for the Veteran Reserve Corps, he was discharged from service on March 22d, 1865, and pensioned. Pension Examiner Alonzo Churchill reports that the patient suffered pain in the head with dizziness, which was increased by exercise, and rates his disability more or less permanent. Case. — Private George W. Gibson, Co. K, 1st Wisconsin Volunteers, aged 34 years, was wounded at the battle of Dallas, Georgia, I^Iay 31st, 1834, by a piece of shell, which fractured the right ])arietal bone, and lodged at the seat of fracture. He was sent to the hospital of the 1st division. Fourteenth Corps, and on June 15th was conveyed to Chattanooga; thence was sent, on the 28th of June, to hospital No. 3, at Nashville. The missile was extracted two months and five days after the injury. On the 30th of August the patient was transferred to the Harvey Hospital at Madison, W'isconsin. There was hemiplegia of the left side which e.xisted up to October 14th, 1864, the date of his discharge and pension. On February 15th, 1868, Pension Examiner J. S. Hurd reports the hemiplegia still continuing ; the ))atient subject to e))ilepsy on slight exertion, and unable to remain in the open air during warm weather without pain in the head. Llis disability is rated total and permanent. Penetrating Gunshot Fractures of the Skull. — Thoiigli the larger number of such accidents are immediately fatal, the sufferers being instantly killed, or lingering for a few hours at the field depots ; yet a not inconsiderable number of cases came under treatment at the hospitals. The following are among the more remarkable examples of survival after penetrating gunshot fractures of the skull : Ca.se. — Private Thomas W. Dillon, Co. E, 3d New Jersey Volunteers, aged 27 years, was wounded at the battle of Chancellorsville, May 3d, 1853, by a musket ball. The ])atient remained within the enemy’s lines some days after receiving the injury, and was subsequently brought to the hos])ital of the Sixth Corps at Potomac Creek. U))on examination it was found PENETRATING GUNSHOT FRACTURES OF THE SKULL. 191 the missile liad entered the cranium very near the superior angle of the occipital bone, and had passed anteriorly into the substance of the brain. There was no comminution, fissuring, or depression of bone about the wound of entrance, nor hernia cerebri. The wound had not been dressed, probably because of the natural sujiposition that the case would prove speedily fatal. After shaving the head and removing a few small fragments of bone, the wound was dressed with cold water, and the patient was placed upon mattresses on the floor of the tent, it being impossible to retain him upon a bed without force. Here he remained for a week, in a contorted position, with pupils dilated, respiration slow, and pulse 50, and passing his evacuations involuntarily. He slept most of the time and only aroused when spoken to loudly. The patient received little attention, the case being regarded as hopeless ; but at the end of ten days he began to retain his evacuations and obey the calls of nature, sleeping generally at night and sitting up during a part of the day. At no time was he conscious of pain, except from light. By the first week of June, the patient’s strength was almost entirely restored ; the wound had closed, and all his functions, except memory, were normal. He remembered nothing since his admission to hospital, and did not recognize intimate relations. On June 13th, 1863, the patient was transferred to Philadelphia, at wdiich time he was able to walk to the station, a distance of nearly half a mile. In April, 1864, he was returned to his regiment in the field, perfectly well physically, but with an intellect somewhat impaired. He remembered all that had occurred previous to the reception of the injury; but from that time till an indefinite period in the autumn, he was totally unconscious. He is not a pensioner. The case is reported by Surgeon Lewis \V. Oakley, 2d New Jersey Volunteers. Case. — Private Francis Reynolds, Co. F, 6th United States Infantry, aged 27 years, was admitted, on June 18th, 1863, to Satterlee Hospital, Philadelphia, with a gunshot fracture of the right parietal bone. A conoidal musket ball had entered the right side of the forehead, and had passed upward and backwnard. On admission the wound had healed, giving no sign of inflammation or suppuration. The patient was frequently troubled with a sharp jiain on the top of the head, a little to the right side, which sometimes caused dizziness. He recovered, and was returned to duty on September 21st, 1833. This man is not a pensioner. Case. — Corporal Andrew Rupp, Co. C, 82d Illinois Volunteers, aged 29 years, was wounded in an engagement at Dallas, Georgia, May 25th, 1834, by a round musket ball which impacted itself in the left temporal bone. He was admitted to the hos- pital of the Twentieth Corps; on June 1st, sent to the field hosjjital at Chattanooga; and on June 9th, to the Sherman Hospital at Nashville, whence he was furloughed on July 16th. At the expiration of his leave, August 15th, 1834, he was admitted to the Desmarres Hospital, at Chicago, Illinois. The wound h.ad not healed; cold water dressings were applied. On December 23d, the greater portion of the ball was removed. Slight discharge followed the operation and continued for some weeks, after which the wound readily cicatrized. He was discharged from service on May 23d, 1835, and pensioned. At that time he experienced but little, if any, inconvenience from the remaining portion of the impacted ball, which it was found inijn-acticable to remove. Pension Examiner J. P. Lynn, August 10th, 1837, reports thickening, tilling uji, and complete deafness of patient’s left ear, and rates his disability one-third and permanent. Case. — Private John Daly, Co. C, 106th New York Volunteers, aged 22 years, was wounded near Petersburg, Virginia, April 2d, 1865, by a. conoidal ball, which penetrated the frontal bone a little to the left of the median line. He was, on the fol- lowing day, admitted to the depot field hospital of the Sixth Corps, and on April 7th, was transferred to the Stanton IIosj)ital, Washington. Simple dressings only were applied to the wound. The case progressed favorably, and on June 5th, 1865, Daly was discharged from service, and was pensiomxl. On March 29th, 1835, Pension Examiner George S. Gale reported that this man appears odd, but quite shrewd. He could then discover no signs of paralysis, but the patient complained of dizziness when stooping. His disability is rated total. Case. — Private Samuel P. Ingram, Co. G, 48th Illinois Volunteers, was wounded at Dallas, Georgia, August 14th, 1834, by a conoidal ball, which entered at the outer edge of the left superciliary ridge of frontid bone, passed backward and downward, invoK'iug in its course the lower surface of anterior left lobe of cerebrum. He was on the same day admitted to the hosj)ital of the Fifteenth Corps, whence he was furloughed on August 24th. On January 15th, 1835, he was admitted to the hos])ital at Evansville, Indiana, and was discharged from service on January 27th, 1865, and pensioned. On June 21st, 1866, I’ension E.xaminer J. J. Lesher, reported that there is a small depression :^om loss of hone at the wound of entrance. Tlie patient’s mind is slightly afifected, and he is guilty of irregularities both mental and moral. He rates his disability at one-fourth and per- manent. Case. — Private Solomon Farr, Co. F, 17th Maine Volunteers, was wounded at Gettysburg, Pennsylvania, July 2d, 1833, by a conoidal b.all, which penetrated the cranium. When admitted to the hospital of the 1st division. Third Corps, ho was speechless. On July 16th, he was sent to McKim’s Mansion Hospital at Baltimore. On September 30th was transferred to Patterson Pai’k Hospital of the same city, whence he was returned to duty October 4th, 1803. On May 6th, 1864, he was killed in action at the battle of the IVildemess. Case. — Captain Thomas Church, Co. E, 53d Penns.ylvania Volunteers, received at the battle of Fair Oaks, Virginia, .Tune 1st, 1862, a gunshot wound of the head with injury of the left parietal bone. He was conveyed to Philadelphia, and on the 4th admitted into the St. Joseph Hospital, whence, a few days later, he went home on leave of absence. On February 23d, 1863, being unfit for duty, he was discharged the service, and pen.sioned mi May 9th, 1803. Pension Examiner S. R. Wagenseller, reported that there were several sinuses passing into the skull, communicating with the membranes of the brain. From these sinuses there was a constant disetuarge of pus, which produced headache, vertigo, etc., when redained. Ho was unlit for either physical or mental exertion, and his disability was rated total and doubtful. A communication from the patient, dated .January 17th, 1870, says that his wound has never healed, but remains open and discharges. Case. — Private Andrew .1. McMahon, Co. D, 27tli Michigan Volunteers, aged 19 years, was wounded near I’etorsbiirg, .July 30th, 1864, by a fragment of shell, which fractured the right supi'rior border of the Irontal bone near its articulation with the parietal. Gn the same day he was tidinitted to the hospital of the 3d division, Ninth Corps, and, on August Ist, wtus sent to 192 WOUNDS AND INJURIES OF THE HEAD City I’oint ; Ilicr.cc lie was conveyed by hospital steamer to Lovell Hospital, at Portsmouth Grove, Rhode Island, where he was admitted August 7th, 18C4. In November he was transferred to the Harper Hospital, Detroit, and was discharged the service December iiCth, 16C4, and pensioned. On January 27th, 1668, Pension Examiner W. E. Breakey reported both tables of the bone lost from necrosis, and only a membranous formation covering the opening. There was protr.acted suppurative discharge, acute susceptibility to he.at, vertigo, loss of memory, melancholia, symptoms of compression and general mental impairment, all of which were aggi’avated by labor or excitement. Sometimes, after stooping, he would fall and become unconscious. His disa- bility was rated total, and of the third grade. Case. — Private Richard Markham, Troop C, 4th U. S. Cavalry, was admitted on April 8th, 1863, to Hospital No. 8 at Louisville, Kentucky, with a fracture of the right temporal bone, produced by a piece of shell. The patient was discharged November 28th, 1863, and pensioned. The wound was l epoi ted healed ; but it occasionally discharged pus and pieces of bone. He suil'ered from headache and dizziness, and his general health was impaired ; his disability being rated total and permanent. Case. — Private Warren Mitchell, Troop D, 1st Wisconsin Cavalry, aged 21 years, was wounded in an engagement near Jefferson City, Missotui, October 7th, 1864, by a conoidal musket ball, which fractured both tables of the parietal bone. On the 12th, he was sent to the general hospital at Jefferson City, where simple dressings were applied. During the treatment several spiculffi of bone were removed from the wound. Complete paralysis of the right side and partial paral3’sis of the left ensued. The patient was discharged the sendee JUI3' 10th, 1865, and jicnsioned, his disabilitj' being rated total and permanent. A com- munication from Pension Examiner N. Udell, states that the patient suffers from general paral^'sis; that he has been confined to his bed for twentj' months, and is helpless. Case. — Private Michael Murr.av', Troop F, 3d New York Cavalry, aged 29 years, was wounded while a prisoner at Richmond, in October, 1864, ly a buckshot, which fractured the left side of the cranium. He was p.arolcd, and on March 11th, 1865, was admitted to the 1st division hospital at Annapolis ; subsequently he was sent on March 22d to the Jarvis Hospital at Baltimore; on the 12th of April, to the Ladies’ Home Hospital, New York City; and on May 24th to the McDougall Hospital, Fort Schuyler, New York Harbor, where he was discharged the service June 23d, 1865, and aftenvard pensioned. On August 20th, 1868, Pension Examiner G. S. G.ale reports the process of exfoliation still in progress, and the left part of the whole body in a semi-pandytic state; the arm useless, and the patient rendered quite helpless from frequent convulsio’ns. His disability is rated total and permanent. Case. — Sergeant William L. Henderson, Co. A, 123d Illinois Volunteers, aged 27 years, was wounded in an engagement at Selma, Alabama, April 2d, 1865, by a buckshot, which entered one-half an inch above and anterior to the meatus .auditorius externus, fractured the left temporal bone, and emerged one inch from the point of entrance. He was treated in a field hospital until M,ay 8th, when he was conveyed to the hospital steamer D. A. January. On Maj' 25th, ho entered the hospital at Mound City, Illinois, and on May 31st, 1865, he was discharged the service. The wound had entirelj- healed. On February 7th, 1870, Pension Examiner A. Fei-gusson reported that the ball reirrains imbedded in the bone. The patient suffered from vertigo, with loss of memory, and was unable to labor. He w'as a farmer by occupation ; his general health was good, and his habits were regular. His disability is rated at three-fourths and permanent. Case. — Private Gustave Stork, Batterj"^ B, 15th New Yoi'k Artillerjq aged 25 j'ears. Conoidal ball entered just anterior to the external meatus of left ear and lodged, probabH' in petrous portion of temporal bone. Bull Run, Virginia, August 29th, 1862. No treatment until May 11th, 1864, when he was .admitted to Columbian Hospital, Washington. He was transferred as follows: Maj' 15th, 1864, to Patterson Park, Baltimore; August 17th, to Camden Street, Baltimore, and on September 12th, 1864, to Mow'er Hospital, Philadelphia, where an ineffectual attemiit to remove the ball was made. Discharged from service Juno 16th, 1865. Not a pensioner. Case. — Priv.ate George Potter, B.attery C, 3d ^Massachusetts Heavy Artillery, aged 26 years, received, at the battle of Mcch.anicsville, June 11th, 1864, a penetr.ating fr.acture of the cranium by a conoidal musket b.all, which entered the cavity through the parietal bone. Ho was sent to the hospital of the 1st division, P’iflh Corps, and on June 13th, was transferred to the Finky' Hospital at Washington. 'Phe case progressed satisfactorily’ under simple treatment, and on June 23d; the patient was furloughed. On the 22d of August, he rvas transferred to the Mason Hospital at Boston. P.aralysis of the left side h.ad ensued, and still existed at the time of his discharge, September 10th, 1864. He is not a pensioner. Case. — Private Charles J. Williams, Co. E, 15th Ohio Volunteers, aged 19 years, was wounded at the Rattle of Shiloh, April 7th, 1862, by a missile, which penetrated the right parietal bone at its posterior superior angle. On April 11th, he was taken on board the steamer D. A. J.anuary, and was conveyed to the City Hospital, St. Louis, where he was admitted on April 14th. He w'.as afterwards furloughed, then admitted to Camp Chase, Ohio, and on July 18th, 1862, was discharged the service. In March, 1866, Pension Examiner John C. Hupp reports a circular opening in the patient’s skull of about one inch in diameter and h.alf an inch in depth. The sides of the opening were well covered with integument, the bottom partially so. Ho was also subject to vertigo upon slight exertion. His disability is r.ated three-fouiths and permauent. Case. — Private George W. Hulse, Go. G, 36th Illinois Volunteers, aged 21 years, was wounded at the battle of Chick- amauga, Georgia, September 20th, 1863, by a buckshot which penetrated the occipital bone near the iqiper margin, and lodged in the brain. In the same eng.agement, he was wounded in the chest by a conoidal ball which entered between the seventh and eighth ribs. No attem])t seems to have been made to extract either missile. On the 0th of October ho was conveyed to Stevenson, Alabam.a, for treatment, and one month later, he w.as sent to the Cumberland Hospital, Nashville, Tennessee. On December 2d, he was tran.sferrcd to the ho.spital at Quincy, Illinois. During this lime, simple dressings only had been applied to the wounds. By’ the 1st of March, 1864, the wounds had healed; but the patient was anminic, and suffered more or less pain in the head. On the 11th of the month, ho w.as trausfem'd to the Benton Barracks Hospital, St. Louis, Missouri, and on the BALLS LODGED WITHIN THE CRANIUM. 193 31st, to the Lawson Hospital. The external table was slightly necrosed. He was discharged from service July 5th, 18C4, and pensioned. The case is reported by Acting Assistant Surgeon J. F. Wilson. Information received from Pension Examiner A. F. Hand, on April 12th, 1867, states that the patient suffers from debility, derangement of the urinary organs, and mental imbecility. Case. — Corporal George H. Farnum, Co. C, 16th Maine Volunteers, aged 19 years, was wounded at Gettysburg, July 1st, 1863, by a round ball, which penetrated the cranium. He was sent to the Seminary Hospital, remaim'ng there until the 19th of the month, when he was sent to the hospital at York, Pennsylvania. The treatment, so far as recorded, was simple, He recovered and W’as transferred on the 11th of February, 1864, to the First Battalion of the Veteran Reserve Corps. He is not a pensioner. Case. — Private James Lavery, Co. E, 136th New York Volunteers; Gettysburg, July 3d, 1863; gunshot penetrating wound of the left side of head; admitted to a field hospital; July 9th, sent to Satterlee Hospital, Philadelphia; May 13th, 1864, transferred to Veteran Reserve Corps. His disability is rated three-fourths and permanent. There is a traumatic cataract, and the functions of the right eye and right ear are impaired. Balls lodged within the Cranial Cavity . — Many instances were reported of patients who had survived the lodgment of missiles within the skull ; but few or none resembling the cases reported by Larrey, of balls encysted in the brain and giving no inconvenience for years. It is, indeed, reported that some patients went to duty with balls lodged in the cerebrum ; but the diagnostic details accompanying the histories of these cases are not sufficiently precise to invite the fullest confidence. In most of the cases, in which the evidence that the ball remained within the skull was conclusive, either fistulous sinuses existed, or there was much cerebral disorder, or the position of the missile was discovered after the patient’s death at a period remote from the injury ; Case. — Lieutenant Herman W. Lilycrantz, Co. D, 103d United States Colored Troops, was wounded at Fort Pulaski, December 24th, 1865, by the accidental discharge of a pistol, at a distance of about four feet from his head. The ball perforated the os frontis over the right superciliary ridge. When first seen, fifteen minutes after the accident, he was vomiting freely, and about a fluid ounce of brain njatter had exuded from the -wound. The vomiting being checked, but little blood, and no more brain matter, was discharged. A probe, five inches long, glided easily, by its own weight, its full length directly backward through the wound, without coming in contact with the ball. The pulse was 120, and weak ; blood was freely discharged from the nose, mouth, and ears ; there was considerable extravasation in the cellular tissue of the eyelids and the pupils were dilated. For ten days after the accident the patient showed a tendency to sleep, but was easily aroused and would converse freely, constantly wandering, however, from the topic of conversation. He could neither taste nor smell, and his hearmg and sight were much impaired, bright lights causing much uneasiness. He had very little pain, but was restless and had a constant tendency to take hold of the head of the bed and draw himself toward it. Cold applications were made to the head, morphia was administered and low diet ordered. The pulse gradually declined until December 31st, when it was sixty and eighty. Unto January 20th, there was no change in the symptoms or treatment ; after that, full diet was allowed. On January 24th, he began to take exercise in the open air, and on the 31st, all treatment was discontinued. During the month of February, he had a large axillary abscess. On March 10th, he went northward on furlough, complaining only of muscular weakness and inability to look at a bright light. Occasionallj' pus would ooze from the wound, which was covered by a scab. He was discharged the service May 11th, 1866. In November, 1867, he was examined by Dr. H. J. Bigelow, who found a small scar and a depression over the frontal sinus, the cause, no doubt, of the epilepsy which attacked the patient every two weeks. These attacks were preceded by a distinct aura and by numbness in the left hand. They became less frequent, and otherwise he was doing well. The name of this patient is not u]ion the pension list. The case is reported by Assistant Surgeon H. S. Schell, U. S. A. The regimental surgeon. Dr. Warren M. Babbitt, 103d Colored Troops, of Randolph, Massachusetts, printed a report' of this case, in November, 1867. He records the patient’s name as Libjencrantz ; but in the official roster it is recorded as above.^ In the spring of 1870, Lieutenant Lilycrantz called at the Surgeon General’s Office, and was examined by Assistant Surgeon G. A. Otis, U. S. A. There was a small depressed cicatrix above the inner portion of the right eyebrow. The officer’s replies to questions indicated a dull intellect. He articulated distinctly and there was no paralysis. He was, at this time, seeking an office in one of the executive departments, and probably obtained one, as a notice of his death, in January, 1871, about five years after the reception of the injury, was observed in one of the Washington newspapers. Case. — Private Benjamin B. Claiborne, Troop H, 2d Arkansas Cavalry, aged 23 years, was wounded in an engagement at Osage, Kansas, October 25th, 1864, by a missile which penetrated the frontal bone and lodged. He was immediately conveyed to Fort Scott. The ball was not extracted, but the wound was dressed in the usual manner. The case progressed favorably, and Claiborne was returned to duty on December 22d, 1864. Surgeon A. C. Van Duyn, U. S. V., reports the case. A subsequent report by Pension Examiner E. Bennett, October 8th, 1869, represents the patient as totally disabled, being easily overcome by fatigue or heat, and compelled to assume a recumbent posture in frequently recurring attacks of vertigo. Case. — Private William Sheridan, Battery I, 5th Ohio artillery, aged 21 years, was, on May 27th, 1865, admitted to hospital at Little Rock, Arkansas, with a gunshot wound through the left temporal region. The missile lodged in the brain. He recovered, and was discharged on June 20th, 1865. He is not a pensioner. * Bo$ton Medical and Surgical Journal^ Vol. LXXVII, p. 340. ^Official Army Register of the Volunteer Force^ Part VIII, p. 284. Washington, 1867. 194 WOUNDS AND INJUEIES.OF THE HEAD, Case. — Private John H. Secliler, Co. H, 21st Wisconsin Volunteers, aged 21 years, was wounded in the engagement at Bentonville, Nortli Carolina, March 19th, 18C5, by a conoidal ball, wliich struck the os fi'ontis over the right eye and passed into the brain. He was admitted to the hospital of the 1st division. Fourteenth Corps; on April 5th, sent to the Foster Hospital at New Berne, North Carolina; on April 12th, to the Grant Hospital, New Yoik Harbor, and on Slay 29th, to the Swift Hospital at Prairie du Chien, Wisconsin, whence he was returned to his regiment on August 3d, 1865, for muster out. He is not a pensioner. Case. — Private John Wolstenholm, Co. B, 37th Indiana Volunteers, aged 25 years, was wounded at the battle of Lost Mountain, Georgia, June 17th, 1864, by a conoidal musket hall, which entered the mastoid process of the temporal bone and penetrated the brain. On the same day, he was admitted to the hospital of the 1st division. Fourteenth Corps; on June 26th, was sent to Hospital No. 1, Nashville, thence was transferred, on June 29th, to the Totten Hospital at Louisville ; and on July 12th, was admitted to the Soldiers’ Home Hospital at Indianapolis. He recovered, and was discharged the service July 24th, 1865. Pension Examiner J. S. McNeily since reports the patient entirely deaf in right ear, the right eye irritable and injected, with constant pain in the right side of the head, impairment of the mental faculties, tendency to vertigo upon slight exertion ; and rates his disability total, and permanent. He believed that the missile had not yet been removed. Case. — Private William McCann, Co. C, 1st Maryland Eegimeut, received a penetrating gunshot wound of the head, and was admitted to hospital No. 1, Eichmond, Virginia. The missile was not extracted. He was discharged fi’om the service January 27th, 1864, on recommendation of Surgeon C. B. Gibson, P. A. C. S. Case. — Private William A. Andrews, Co. D, 25th Massachuisetts Volunteers, was wounded at the battle of New Berne, North Carolina, March 14th, 1862, by a buckshot, which entered the right ear, back of the meatus, penetrated the bone, and lodged within the cranium. On March 18th, he was admitted to the Academy Hospital, New Berne; was furloughed on April 20th, and was discharged the service October 10th, 1862, and pensioned. On December 12th, 1862, Pension Examiner Oramel Martin reports the wound still discharging, and the patient complaining of stiffness in the cords of the neck, with weakness of the right arm, he being unable to move it for five weeks, except with the assistance of the left hand. He was still weak, but gradually gaining strength. At times he was subject to slight deafness. In a subsequent report, dated October 19th, 1860, he says that the missile still remained in the brain, that the wound was discharging pus, and that a sinus was opening back of the ear ; that his general health was impaired ; and that his disability is rated one-half and permanent. Case. — I'rivate William E. Worley, Trooj) K, 9th Indiana Cavalry, aged 20 years, was wounded at Franklin, Tennessee, December 23d, 1864, by a conoidal ball, which entered the right external ear, passed downward and backward, and lodged, fracturing the occipital bone. He was taken to the post hospital at Columbia, and on January 19th, was sent to hospital No. 2 at Nashville. On July 20th, the patient was transferred to Crittenden Hospital, Louisville, thence to Jefferson Hospital, Indiana, and on July 26th to Indianapolis, where he was mustered out of service August 23th, 1835, and pensioned, his disability being rated one-half and probably permanent. At the date of the patient’s discharge, it was reported by Pension Examiner M. H. Harding that he suffered pain and vertigo after any active exercise. Accompanying this information was the sworn deposition of the patient stating the fact that freipient ju’obings had failed to reach the ball, that small pieces of bone were discharged at the time of the probing, and that the wound was a running sore, at times painful. Case. — Corporal Edward Steible, Co. G, 43d Illinois Volunteers, was wounded at the battle of Shiloh, April 7th, 1832, by a musket ball, which entered the frontal bone one inch above the superciliary ridge, and one inch and a half from the median line, passed through the skull backward and downward, and lodged. The patient was taken on board the steamer Empress on Apiil 20th, ^vas sent to the hospital at Keokuk, Iowa, and on July 17th to the New House of Eefuge Hospital, St. Louis, where he was discharged June 3d, 1863. The seat of the ball, which still remained in the head, could not be ascertained, and the wound was still suppurating. A probe, introduced into the fistulous wound, passed through the cribriform plate of the ethmoid, and api)eared in the nasal cavity. The man was continually subject to vertigo. He was pensioned, his disability being rated total and permanent. Case. — Private William Cromwell, Co. G, 7th Ohio Volunteers, was admitted, on December 17th, 1862, to the Continental Hotel Hospital, Baltimore, with a penetrating wound of the cranium caused by a buckshot, which entered at the junction of the parietal with the occipital bone. On May 1st, 1863, he was transferred to Fort Wood, New York Harbor, and was discharged the service May 28th, 1863, and pensioned. A report from Pension Examiner O. Pomeroy says that the shot still remains within the cranium, and that the patient suffers from constant headache and frequent attacks of epilepsy, rendering him unable to obtain a livelihood; and rates his disability total and permanent. Case. — Private August McClellan, Co. C, 28th Massachusetts Volunteers, was wounded at the battle of Fredericksburg, December 13th, 1862, by a missile which penetrated the frontal bone, over the left superciliary ridge, and remained within the cranium. He was admitted to the hospital of the 1st division. Ninth Corps ; on December 16th, was sent to the hosj)ital at Point Lookout, Maryland ; on May 1st, 1863, to West’s Building Hospital, Baltimore, and on May 9th, to Portsmouth Grove, Ehode Island, where he was transferred to the Veteran Eeserve Corps. He was discharged August 31st, 1866, and pensioned. The patient suffered from vertigo upon exertion. His disability was rated total. Case. — Corporal John W. Cool, Co. D, 52d Virginia Eegiment, aged 22 years, was wounded at the battle of Winchester, September 19th, 1864, by a conoidal ball, which fractured the occipital bone and entered the brain. He was treated at Winchester until the 18th of December, when he was sent to West’s Building Hospital at Baltimore. The treatment throughout wa*s of a very simple character. The patient recovered, and was transferred on January 5th, 1865, to Fort McHenry for exchange. On March 24th, 1835, he was examined by a Confederate retiring board. 'Tlie missile was a source of constant irritation to the brain, and the board declared that the patient was unable to perform held duty, but might be employed at some post where the duties were not laborious. BALLS LODGED WITHIN THE CRANIUM. 195 Case. — Private Jonatlian Wiser, Co. E, 49tli Pennsylvania Volunteers, aged 35 years, was wounded at tlie battle of the IVilderness, May 5tli, 1864, by a conoidal musket ball, which fractured and slightly depressed the cranium. He was at first admitted to the hospital of the 1st division. Sixth Corps, and, on May 12th, was sent to the Mount Pleasant Hospital, 'Wash- ington. The records of the latter hospital state that the ball had not been extracted. On September 24th, he was admitted to the Frederick Hospital, Maryland, where he remained under treatment until June Cth, 1865, when he was discharged from service. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. This patient is not on the pension list. Case. — Private John E. Leland, Troop E, 1st Illinois Cavalry, was wounded by a gunshot missile, probably a buckshot, which entered the mastoid process of the left temporal bone close behind the middle of the pinna, passed slightly forward and lodged in the cranium, but its exact locality could not be ascertained. The pinna had become adherent to the scalp at the entrance of the wound. The patient suffered pain in the region between the entrance of the wound and the eyebrow. Active e.xercise, or stooping, would produce dizziness and pain. The vision and hearing of the left side were slightly impaired. He was discharged the service March 14th, 1862, and pensioned, his disability being rated one-half and temporary. Case. — Corpoi’al William G. Davis, Co. A, 105th Ohio Volunteers, aged 30 years, was wounded at the battle of Chick- amauga, Georgia, September 20th, 1863, by a conoidal musket ball, which fractured and penetrated the right temporal bone, and lodged within the cranium. On September 29th, he was admitted to the hospital at Chattanooga, Tennessee, thence was trans- ferred on October 6th to Stevenson, Alabama, and on October 12th to Nashville, where he remained under treatment until June 18th, 1864, when he was sent to the Totten Hospital, Louisville, Kentucky. On July 15th, he was sent to the hospital at Cleve- land, Ohio, and mustered out of service May 31st, 1865, and pensioned. Since the patient’s discharge he has suffered from headache and vertigo, and impaired functions of right eye and ear. His disability is rated total and permanent. Case. — Private William Sheridan, Battery M, 1st Missouri Artillery, aged 34 years, was wounded at the siege of Vicks- burg, May 19th, 1863, by a canister shot. The missile entered the left parietal bone, immediately posterior to the coronal, and three inches from the sagittal suture, passed horizontally inward, a distance of two and a half inches (as stated by the Surgeon who probed the wound at the time of receipt of injury), and lodged. He was taken on board an hospital boat, where an unsuc- cessful attempt was made to extract the ball. On May 25th, the ])atient was admitted to the Van Bureu Hospital, where he remained some weeks, going about the hospital, dressing his own wound, and suffering but little inconvenience. He was returned to his battery, and on September 3d, 1863, was discharged from service. At that time, and for weeks previous to his discharge, the wound suppurated freely, and occasionally bled, and small fragments of bone escaped. In November, he was ])laced to work on the levee by the Commissary Department. The work was heavy, but he experienced no trouble, except on approach of a storm, when he had a dull pain and sensation of weight. He was, however, attacked with fever, and on December 14th was admitted to hospital No. 12, Na.shville, and on December 28th sent to hospital No. 1, of the same place. On January 3d, 1864, the patient was convalescent. The cicatrix is hard and bony, and about on a level with the inner table. The edges of the opening through the outer table are quite abrupt. He was returned to duty on February 24th, 1864. He is not a pensioner. Case. — Private Samuel D. Solomon, Co. G, 3d New Jersey Volunteers, was wounded in an engagement at Bull Run Bridge, August 27th, 1862, by a carbine ball, which struck at a point two inches behind the tip of the left ear, and produced, apparently, only a scalp wound across the median line. He fell to the ground, but retained his consciousness. When seen by the surgeon, a probe was passed along the track of the missile the depth of two inches into the brain substance. The patient was sent to the 3d division hospital at Alexandria. The extent of the injury was not suspected, and the case was treated as a superficial scalp wound. On September 3d, he was admitted to the Broad and Cherry Streets Hospital, Philadelphia. Healthy suppuration continued, and a fragment of bone was discharged from the wound. On November 6th, the wound had healed, and the patient was returned to duty. Two days later he was admitted to the Eyland Chapel Hospital, Washington, suffering from a large abscess in the left ear. On December 5th, he was transferred to the Stanton Hospital. The discharge from the ear had not altogether ceased, and he was suffei'ing constant headache, which was greatly increased by exposure to cold air ; he also suffered from acute darting pains across the base of brain, fi-om the right temple to the scar of the wound. No paralysis existed and the functions of the body were generally well performed. The cicatrix, though tender, was firm. After a few days, he was allowed, at his own request, to serve in the capacity of nurse ; but, in two weeks’ time, he was relieved from this task, as the pain and vertigo were unduly increased, and he was becoming pale and emaciated. He was discharged the service January 19th, 1863. Surgeon John A. Lidell, U. S. V., who reports the case, states, that it was the opinion of several surgeons, who examined the injury, that the missile still lodged in the cranial cavity. On March 2d, 1870, his claim for pension was still pending, and his disability rated three-fourths and probably permanent. Case. — Sergeant Walter Rotherham, Co. D, 7th New Jersey Volunteers, aged 23 years, was wounded at Gettysburg, July 2d, 1863, i)y a musket ball, which penetrated the skull near the right frontal eminence, passed directly inw'ard and lodged somewhere on the membranes or in the brain substance. He was admitted to the hospital of the 2d division. Third Corps, and on July 10th was sent to the .Jarvis Hospital at Baltimore. The opening through the bone was similar to that made by a trephine, and the track of the ball could be followed on the dura mater wdth a probe for a considerable distance, as that mem- brane was detached from its natural connections with the skull. The patient was unable to say whether there had been much hatmorrhage or not. The parts were still open, and in making an exploration, the little linger could be readily inserted through the fracture, but no jagged bone itressing inward could be detected. The membranes were not lacerated at the seat of injury. The pulsations of the brain could be distinctly felt, and it was apparent that the ball had not rebounded or dropped out, but had followed a course toward the back of the skull, where it still was concealed. The patient further stated that, on recovering his senses, he was not in the l(!ast paralyzed, and was able to conver.se, and that his surgeon said : “you cannot jwssibly live.” After a few hours, he again became insensible, and remained so for two days, when consciousness again returned. The ptitient, on admission, was able to sit up, stand, and walk, but he earned his head backward, resting between the shoulders, and complained of great pain and dizziness, if he attempted to change it to an erect ])osition. Tliere was no jyerceptibh? loss of power, motion. 196 WOUNDS AND INJURIES OF THE HEAD or sensation on either side of his body. He was directed to be put to bed, and quiet was enjoined. His hair was then cut short, and cold water dressings were applied. There being no arterial excitement, the treatment was chiefly expectant. His recovery was rapid, and on August 12th, he was furloughed for fifteen days, at the expiration of which time he returned, having sufiered no inconvenience from the journey. The wound, however, had not entirely closed, and since that date several pieces of bone have exfoliated. He was transferred to the Veteran Reserve Corps, and was assigned to light duty in the hospital, but it soon became evident that he was permanently disabled, and he was discharged the service December 19th, 1863, at which time he complained of a constant dull, heavy pain at the back of his head. At night he suffered from unpleasant dreams and hallucinations, which sometimes caused him to wake in a state of great terror. His bowels were obstinately constipated, but were readily relieved by mild cathartics. Occasionally he was annoyed by nausea and vomiting after eating his meals. His mind was not impaired to any perceptible degree. He is not a pensioner. The case is reported by Assistant Surgeon D. C. Peters, U. S. Arm3^ Case. — Private Elijah Lanning, Co. K, 79th Pennsylvania Volunteers, was struck by a missile at the battle of Chicka- maiiga, Georgia, September 19th, 1863, which penetrated the right parietal bone. No particulars of the case can be obtained, until February 17th, 1864, when the patient was admitted to the field hospital at Chattanooga, Tennessee. He received a fur- lough in March, and at its expiration, April 27th, was transferred to the York Hospital, Pennsylvania, suffering at the time from paralysis. On October 5th, 1864, he was mustered out of service and pensioned. A month after, Pension Examiner S. Cleizer reports the ball still remaining within the cranium, causing paralysis of the left arm and both lower extremities, and rates his disability total and likely to be permanent. Missiles Extracted from within the Cranium . — In many cases attempts were made to remove projectiles which had penetrated the cranial cavity, and even imbedded them- selves in the substance of the cerebral hemispheres. Though most of these cases had a fatal termination, the evidence seems conclusive that, in a few, this operation was success- fully accomplished : Case. — Lieutenant Andrew M. Brown, 15th U. S. Infantry, received at the battle of Wilson’s Creek, Missouri, August 10th, 1861, a penetrating gunshot wound of the cranium. On the same day, he was admitted to the hospital at Springfield. He recovered, and was returned to his regiment, then the 1st Missouri Infantry, for duty. The ball was successfully removed from the wound in 1868, seven years after the reception of the injuiy. In January, 1871, this officer was on duty as a Captain in the 13th Infantry. Case. — Corporal David Patterson, Co. E, 8th New Jersey Volunteers, aged 37 years, was wounded at the battle of Chancellorsville, May 3d, 1863, by a conoidal ball, wliich penetrated the left parietal bone. He was admitted to the Log Hos- pital, Chancellors ville, and on June 8th, was sent to the Mower Hospital, Philadelphia. The ball had been extracted prior to admission, and several pieces of bone had come away. The pulsations of the brain were visible through the wound. During the months of June, July, August, and September, fragments of bone continued to come away, but on October 20tb, the wound had healed with the exception of a small point. He had been transferred to the Veteran Reserve Corps on August 20th, 1863. On September 1st, 1864, he was discharged the service and pensioned. Subsequent information states that the patient’s symp- toms, indicating lesion of the brain, are on the increase. His disability is rated one-half. Case. — Private Joseph Shortz, Co. A, 15th United States Infantry, aged 25 years, was wounded in an engagement at Jonesboro’, Georgia, September 1st, 1864, by a conoidal musket ball, which penetrated the frontal bone on the right side, and lodged: He was immediately admitted to the hospital of the 1st division. Fourteenth Corps, suffering, apparently, little from the shock of the injury, and nothing of special note is mentioned until the 12th, when the operation of extracting the missile was successfully performed. No ill results ensued. He was kept quiet in his quarters until the 23d of October, when he was transferred, by way of Chattanooga, to Nashville, Tennessee, where he w’as admitted into Hospital No. 1, on October 27th. On November 2d, he was furloughed, and on December 20th, was admitted to the hospital at Keokuk, Iowa. At the expiration of his term of service on the 22d of February, 1865, he was transferred to Davenport, Iowa, for muster out. He is not a pensioner. Case.— Private Edward Ware, Co. F, 13th Iowa Volunteers, aged 24 years, was wounded near Atlanta, Georgia, July 20th, 1864, by a conoidal musket ball, which fractured both tables of the frontal bone at the upper border, left side, and pene- trated the brain. He was admitted to the hospital of the 4th division. Seventeenth Corps, on July 30th; on August 3d, w’as transferred to the hospital of the Seventeenth Corps, and on August 10th, w’as sent north. No records of the case can be found, until December 19th, when Ware was admitted to the hospital at Keokuk, Iowa, from furlough. The ball had been rem’oved by incision on November 6th, 1864, and simple dressings had been applied. The wound was still open, but looked healthy. On January 2d, 1865, Ware was transferred to Davenport, Iowa, for muster out, and discharged June 2d, 1865, and pensioned. Subsequent information states that this man is a confirmed epileptic. Case. — Private Morris Winkler, Co. C, 26th Wisconsin Volunteers, was wounded at Gettysburg, July 1st, 1863, by a missile which penetrated the frontal bone near the right eminence, and entered the brain. He was admitted to the Seminary Hospital, and on July 8th, was sent to Twenty-fourth and South Streets Hospital, Philadelphia, where the missile was removed by Acting Assistant Surgeon F. F. Maury. The patient recovered, and on September 17th, 1864, was transferred to the Veteran Reserve Corps. He was discharged the service June 30th, 1865, and pensioned on June 23d, 1868. Pension Examiner L. D. McIntosh, reports that the patient suffered impairment of sight in the right eye, dizziness and headache. His disability is rated total and permanent. BALLS LODGED WITHIN THE CRANIUM. 197 Case. — Private William Duffy, Co. E, G9tli New York Volunteers, aged 28 years, was wounded at Autietam, September 17th, 1862, by a conoidal ball, which entered the left parietal about its junction with the squamous portion of the temporal bone, p.assed downward and backward, and lodged in the substance of the brain. He was insensible about an hour, at the expiration of which time the missile was removed. The right arm and hand were paralyzed. The patient was admitted to the Sixteenth and Filbert Streets Hosi)ital, Philadelphia, Se])tember 2Gth, 1862, where he gradually recovered, under expectant treatment. He was sent to the Ladies’ Home Hospital, New York City, M.ay 26th, 1863, and was transferred to the Veteran Reserve Corps July 29th, 1863. He had nearly recovered the use of his hand and arm. Acting Assistant Surgeon J. W. S. Norris reports the case. This man was discharged the service November 4th, 1864, and pensioned. On April 7th, 1869, Pension Examiner J. Neill reports him suffering from paralysis of the right arm, with defective articulation, and rates his disability total and permanent. Case. — Private William E. Chapman, Co. E, 69th New York Volunteers, was wounded near Petersburg, Virginia, March 25th, 1865, by a conoidal musket ball, which caused a penetrating fracture of the temporal bone. He was, on the same day, admitted to the hospital of the 1st division. Second Corps, and thence was conveyed to Washington, and admitted to the Cami)- bell Hospital, on March 28th, where the missile was removed. He was discharged on May 30th, 1865. On May 15th, 1868, Pension Examiner M. C. Hazen reported that, from time to time, pieces of bone have been discharged from the ear. There was a constant discharge from the ear, with a continued dull pain in the head, and the jaw was anchylosed. His disability is rated three-fourths and temporary. Case. — Sergeant Frank D. Hamilton, Co. E, 28th Massachusetts Volunteers, aged 22 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket hall, which apparently pi’oduced only a scalp wound. He was sent to the hospital of the 1st division. Second Corps, thence was conveyed to Washington, and on the 7th, admitted to the Harewood Hospital. On June 16th, he was transferred to the Knight Hospital at New Haven, Connecticut, where it was discovered that the fi’ontal bone had been fractured. The treatment throughout was of a simple character. In November, the patient was sent to the Dale Hospital, Worcester, JIassachusetts; was discharged from service on the 3d of January, 1865, and pensioned, his disability being rated total and permanent. On March 5th, 1868, Pension Examiner C. L. Fisk, jr., reported that the ball had been extracted from the brain, but that the patient had been much prostrated ever since, and was growing worse. Case. — Commissary Sergeant Abraham F. Debaun, Co. I, 1st Kentucky Cavalry, was wounded at Fair Garden, Tennessee, January 28th, 1864, by a conoidal ball, which entered the forehead at the right superciliary ridge, and passing backward and outward, apparently emerged immediately behind the right eye. He was admitted, on February 1st, to the hospital at Knoxville, Tennessee. On February 7th, he was returned to duty; but, on February 12th, was again admitted to hospital No. 1, Nashville. The wounds of entrance and of exit had cicatrized, and the patient suffered little or no inconvenience. On February 13th, he was transferred to Frankfort, Kentucky, and was discharged December 31st, 1864, suffering from headache, neuralgia, and heaviness about the head, with occasional dimness of vision and almost constant discharge from the wound of a dirty sanious pus. In 1870, he came to Dr. Preston Peter at Louisville, Kentucky. The symptoms were the same as at the date of his discharge, and occasionally, when the wound became temporarily closed or failed to discharge fi’eely, he would become sleepy, approaching an apoplectic coma, and the sight of the eye would be much impaired. An operation for the purpose of removing, as was supposed, depressed and necrosed bone, was decided upon and performed by Dr. D. Cummins, assisted by Drs. .1. A. Brady and P. Peter. A crucial incision was made directly over the point of entrance at the internal angle of the right superciliai’y ridge; a fungous and cartilaginous growth was now removed, and numerous small vessels ligated. An opening through the external table of the frontal bone was then discovered, and upon trimming off the ragged edge with bone-pliers, evidences of lead were found. An elevator was introduced, and two pieces of lead, each about one-third the size of an ounce ball, besides numerous small particles, all lying in the right frontal sinus, were rernoved. When this was done, the internal table was found to be slightly depressed, with an opening'in the depression communicating with the dura mater opposite the site of the fragments of lead. As the patient had never suffered from epilepsy, it w'as not deemed advisable to remove the depressed bone. The wound was closed with sutures, and isinglass plaster and water dressings were applied. He improved rapidly, without any untoward symptoms, and in ten daj’s left for his home. In August, 1870, the patient was hearty, had gained considerable flesh, and was free from headache, neuralgia, dimness of vision, or anything of the Ijincl. He is a pensioner.* Case. — Private Jonathan U. Smith, Co. K, 20th Ohio Volunteers, aged 20, was wounded at Goldsboro’, North Carolina, by a missile, which struck near the centre of the left parietal bone and carried away a portion. The ball was removed seven days after the reception of the injury. The patient was discharged the service April 3d, 1865, and pensioned. Subsequent information, dated June 15th, 1865, states that he was. unable to exert himself without severe pain in the head, and that he was affected by the vicissitudes of the weather. His disability was rated three-fourth^ and temporary. Case. — Private Andrew Gallagher, Co. D, 11th U. S. Infantry, was wounded at Gettysburg, July, 1863, by a conoidal ball, which struck on the outer side of the left orbit, penetrated behind the eye, and lodged. He was admitted to the hospital of the 2d division. Fifth Corps, and on July 13th, was sent to the Camden Street Hospital at Baltimore. On September 25th, he was sent to Fort Independence, Boston Harbor, and there discharged from service on January 5th, 1864. On April 28th, 1864, Pension Examiner W. S. Searle reports that the ball had been extracted, but the vision of the eye was gone ; the eyeball was one-third less in size, and the pupil was insensible to light. Sudden shocks would give gi’eat pain in the eye ; the loss of memory was almost complete, and much pain was felt in the hand. He rated his disability total and permanent. ‘This case is reported in the American Practitioner, Vol. II, p. 332, Louisville, 1870. 198 WOUNDS AND INJURIES OK THE HEAD, The successful removals of projectiles from the cranial cavity were exceptional. In the majority of cases such attempts were unavailing. Yet a temporary amendment was observed in a number of interesting cases of extraction of balls from the interior of the skull : Case. — Captain Ezra Dickermaii, Co. I, 20tl) Connecticut Volunteers, aged ’Jo years, was wounded at the battle of Peach Tree Creek, Georgia, July 20th, 1864. The missile entered about an inch behind and on a level with the outer angle of the left eye, passed inward and forward, and carried away a portion of the anterior surface of the greater wing of sphenoid, one-eighth of an inch in diameter. He was sent to the hospital of the Twentieth Corps, which he reached in an insensible condition. Attempts were made to find the ball, but without success. He remained unconscious for several days, and was, in the meantime, transferred to Vining’s Station, thence to Chattanooga, which place he reached on July 27th. He had at that time become rational, and complained of pain, but was delirious at times. On July 31st, he was sent to Officers’ Hospital, Nashville, bearing the journey well. On August 1st, at his own reejuest, chloroform was administered, and a second search was made for the ball, which was found lodged in, or near the ethmoid bone. So firmly was it imbedded, that it took two assistants to hold the head, while the surgeon, wrapping his handkerchief round the handle of the forceps, was obliged to pull with all his strength. The operation resulted favorably, and in a week the patient left for his home in Connecticut. Then; was complete loss of sight and smell of left side, and the hearing was much impaired. The orbit of the left eye itself was not jterceptibly injured, and singu- larly enough the iris responded freely to the action of light. The patient showeil a general want of intellectual vigor, but with the exception of a loss of memory, no faculty seemed to have especially suffered. He remained on light duty until May, 1865, when he joined his regiment, and was mustered out Juue 13th, 1865. But he had not recovered; working in the sun or severe mental application would invariably bring on vertigo and headache. In the summer of 1866, an epileptic convulsion supervened, lasting about fifteen minutes. Subsequent prostration was relieved by tonic treatment, and in a week he was as well as before the attack. Six months later he had a severe attack of colic; the following day a second epileptic attack occurred, this time very slight, with only momentary loss of consciousness. A third attack occurred in December, 1867 ; there were no convulsions, but rigidity .and unconsciousness lasted about half an hour. Foaming at the mouth and a dull heavy pain in the forehead supervened, with frequent pulse and considerable languor. Facial neuralgia along the portio dura followed, and continued for three days, ^vlien all pain ceased ; drowsiness came on, which passed into coma, and death occurred December 22d, 1867. At the post-mortem examination the dura mater was found much congested over the whole upper surface. On its summit was found a deeply congested spot an inch in diameter. On separating the two layers of the arachnoid, transparent threads of lymph were seen passing from one to the other. At the apex of the brain, corresponding to the deeply congested spot on the dura mater, and dipping down between the hemispheres, more firmly organized lymph was found, uniting the layers of the arachnoid so firmly that they were only separated with difficulty. The substance of the brain presented a healthy appearance, and the ventricles contained no Huid. At the bottom of the middle lobe of the left hemisphere an abscess was found, containing two or three ounces of dark-colored and oflensive jius. The membrane which formed the cyst was firmly united together, and to the bone beneath; the upper portion was delicate and transparent like the arachnoid ; the bone was neither roughened nor discolored. At the anterior border of the portion of abscess adherent to the bone was a small orifice one-eighth of an inch in diameter communicating with the j)terygoid fossa, on a line with the track of the ball and evidently caused by it. The case is reported by Surgeou J. Wadsworth Terry, 20th Connecticut Volunteers. Case. — Private C. W , Co. E, 14th West Virginia Volunteers, aged 22 years, was admitted to the general hospit.al at Frederick, Maryland, September 17th, 1864, coining by rail from the hospital at Sandy Hook, having been ^vounded at Berry- ville, Virginia, on September 3d, by a conoidal musket ball which entered the left temporal bone an inch above the auditory meatus, passed inward and forward, and a little upward. Acting Assistant Surgeon J. H. Bartholf reports that he passed a probe with gre.at freedom four and a half inches into the wound. There was paralysis of the second, thii'd, fourth, fifth, sixth and seventh oraaial nerves of the left side, and total blindness of the left eye, with dilatation of the pupil aud insensibility of the iris and retina, anassthesia of the cornea and conjunctiva of the left half of the face. On one occasion, a pin was stuck into the scalp of the forehead by an awkward nurse and^the patient did not know of the accident. The facial aud masticating muscles of the left side were powerless. He had perception of strong odors, as of the vapor of ammonia. He was totally deaf in the left ear. The left corner of his mouth drooped ; the left eyelids remained open. The discharge from the wound was consid- erable. 'I'lie wound did not communicate with the external auditory canal ; but in about a week an abscess opened and dis- charged through this channel. The patient was tolerably strong, and his general condition was very fair. The patient had no headache ; his pulse, skin and bowels were normal; he was perfectly conscious ; his articulation thick, but iinju-oving daily. On September 18th, Acting Assistant Surgeon Bartholf succeeded in finding and extracting Iroin an inch and a half within the skuli one-third of a conical bullet. From that time onward the patient rapidly improved. The removal of the foreign body was immediately followed by a very free flow of pus. On September 20th, there was some vision of the left eye. The next day the patient could count figures held near the eye. The hearing of the left car returned sufficiently for the patient to hear loud speakings By October 10th, the patient was going about the ward iu comparatively good health, except that there was ptosis, a little discharge from the, ear, and slight suppurations from the entrance wound. The patient voluntarily assisted in nursing, but becoming fatigued complained of slight pain in his temple. On November 2d, two months after the reception of his wound, the patient was transferred to the hospital at Grafton, West Virginia, whence Surgeon S. N. Sherman, U. S. V., wrote to Assistant Surgeon E. F. Weir, U. S. A., that the wound was healed when the patient came to him, but that there was some discharge from the e.ar; that he had learned from the attendants that the patient had drank immoderately of spirits on his ^vay from Frederick to Grafton; one of the nurses stating that he drank at least a (piart of whiskey on the day prior to his arrival at Grafton. Yet he seemed tolerably well on the day of his arrival and on the following day; but on November 4th BALLS LODGED WITHIN THE CEANIUM. 199 he had a severe chill in the morning, and on the 5th convulsions with strabismus of the right eyeball. On the morning of the Gth he died, iifter a convulsion accompanied by opisthotonos. Twenty-eight hours after death a post-mortem examination was made. After removing the calvaria and the brain, a poition of a conoidal musket ball, comprising nearly two-thirds of the missile, was found resting against the sella Turcica, having traver.sed the long diameter of the temporal, being cut off very clean. Dr. Sherman adds that he understands that the other third of the ball was removed from beneath the scalp ; but Dr. Bartholfs notes are conclusive as to the position of the other frag- ment. Dr. Sherman preserved the patient’s skull, with a view of forwarding it with a histoiy of the case to the Surgeon General’s Office; but the specimen was never received at the Army Medical Museum. The notes furnished by Dr. Bartholt^ and a conversation of Dr. Sherman with the editor of this work, have permitted the completion of this history. The fragment of the bullet, extracted by Assistant Surgeon Bartholf^ is figured in the adjacent wood-cut. It weighs nearly half an ounce. Fig. 100. — Frag- ments of ball ex- tracted from tlie brain. Sp. 5555, Sect. I, A. M.M. Case. — Private O. E. Lawless, Co. E, 28th Virginia Regiment, aged 45 years, received, near Richmond, Virginia, .Tune 17th, 18G4, a penetrating gunshot fracture of the frontal bone, the missile entering near the left eminence. On the following day, he was admitted to Chimborazo Hospital No. 5 at Richmond, where the ball was extracted, and expectant treatment was used. The patient suffered some pain, but was in good condition, the tongue being natural, and pulse seventy-two, but intermittent. On June 20th he was in possession of all his faculties and doing well, and on June 22d the pulsations were visible through the wound. On June 2Gth, his pulse was natural, but he kept his eyes closed, only opening them when spoken to. He answered questions, but was little inclined to talk. There was a collection of pus which rose and fell with the pulsation of the brain. The patient died June 27th, 1834, without exhibiting any violent symptoms. Case. — Piivate Francis Donohue, Co. B, 83d Penn.sylvania Volunteers, aged 19 years, was wounded at the South Side Railroad, Virghiia, March 31st, 1885, by a conoidal projectile which penetrated the frontal bone one inch above the right frontal eminence. He was sent to theosp hital of the 1st division. Fifth Corps, and thence was conveyed to Washington, and admitted to the Lincoln Hospital on April 4th. On the 13th, the patient being in a comatose condition. Acting Assistant Surgeon John Morris extracted a large portion of the frontal bone and removed the ball. There was extensive laceration of the integument and considerable comminution of bone. Considerable brain substance escaped through the opening in the craiuuTn. Expectant treatment was resorted to, in spite of which the patient sank rapidly, and died April IGth, 18C5. A post-mortem examination revealed a large abscess in the anterior lobe of the right hemisphere. The case is reported by Surgeon J. C. McKee, IT. S. A. Case. — Private Thomas J. C , Co. B, 28th New York Volunteers, was wounded at the battle of Antietam, September 17th, 18G2, by a spherical projectile which entered near the centre of the forehead, passed downward through the anterior lobe of the right hemisphere, penetrating the roof of the orbit, and lodging near the apex. He was conveyed by rail to Philadelphia, a distance of one hundred and fifty miles, and was admitted to 24th and South Streets Hospital on September 26th, 1862. The right eye, which was in a sloughing condition, was extirpated next day and the missile removed. Death cccurred October 4th, 18G2. At the autopsy, a large abscess was found behind the orbit pressing on the base of the brain, with e.xtensive softening and infiltration in its vicinity. The pathological specimen is No. 21(), Sect. I, A. M. M. A section of frontal bone perforated just above the inner angle of the right orbit. The fractured portion, externally, measures one inch in diameter ; and three depressed fragments of the anterior wall of the sinus remain attached to the edge of the opening. Two square inches of the inner table have been c.arried away, including a portion of the orbital plate. A fissure extends downward through the entii’e thickness of the supra-orbital arch, and a second fissure traverses the plate of bone between the frontal sinuses. The specimen was contributed by Surgeon J. Hopkinson, U. S. V. Case. — Sergeant J. Tf'ilds Williamson, Co. B, 21st South Carolina Cavalry, aged 27 years, was admitted in May, 1864, to South Carolina Hospital, Petersburg, Virginia, with a gunshot fracture of the skull, received May Gth, 1864. The missile, which had entered the centre of the occipital bone, was extracted on the field. Considerable loss of brain matter ensued, and the patient died May 10th, 18G4. Case. — Sergeant Aurelius A. Robinson, Co. I, 17th Maine Volunteers, was wounded at the battle of Gettysburg, July 2d, 1833, by a conoidal ball which struck the forehead, penetrated the outer table of the skull, and became impacted in the inner table. He was sent to the 1st division hospital of the Third Corps. On examination, the ball was found flattened quite thin, with very ragged edges. These points and indentions \vere so closely matched by corresponding ])oints and depressions on the skull, that a fine probe could not be inserted between them. The ball was removed with forceps by Surgeon II. F. Ijyster, 5th Michigan Volunteers. The case proved fatal July Gth, 1863. Case. — Private Montellion Smith, Co. H, 5th Vermont Volunteers, aged 39 years, was wounded at the battle of Cedar Creek, Virginia, October 19th, 1864, by a conoidal musket ball, which struck the squamous portion of the left temporal bone. The ball was extracted on the field. He was admitted to the hospital of the 2d division. Sixth Corps, and on October 23d was sent to the Cuyler Hospital, Philadelphia. The patient stated that he was stunned and unconscious for five hours after the reception of the injury. On admission, the wound looked favorable. On the 26th, his memory began to fail, articulation became difficult, and stupor and muttering delirium followed. On the 28th, the wound was enlarged, when an extensive fracture of the bone was disclosed. Cold water dressings were a])plied continuously ; the pupils of the left eye became much contracted, urine passed involuntarily, and death occurred on November 3d, 1864. At the autopsy, several fragments of bone were found imbedded in the brain substance. The dura mater near the wound was disorganized and coated with a i)urulent and lymphy depo.sit. A large abscess extended to, but did not open into, tlui lateral ventricle ; there was considerable interstitial congestion through the brain. 200 WOUNDS AND INJUEIES OF THE HEAD, Case. — Corporal McD , Troop F, Cth South Carolina Cavalry, was wounded February 10th, 1804, by a conoidal ball, which perforated the skull under the superior curved line of the right side of the occipital bone. He was admitted to the field hospital at John’s Island, South Carolina, on the same day. The perforation was round and smooth, and allowed the entrance of a body no more than one and three-eighths of an inch in circumference, the ball having perforated the occipital with the apex only, falling out afterward. After diligent search, half of the missile was found under the scalp, one inch from the original injury, and was easily removed. The patient died February 11th, 18114. The missile, a conoidal ball, which appears to have struck base first, obliquely flattened, and from which a portion is wanting, is represented in the adjacent wood-cut. It was contributed by Surgeon S. Brillantowski, 41st New York Volunteers. Case. — Corporal John Sponsler, Co. H, 48th Pennsylvania Volunteers, was wounded at Campbell’s Station, near Knoxville, Tennessee, on November 29th, 1863, by the plug of a shell, which passed through the skull near the coronal suture. He was admitted to the field hospital of the Ninth Corps, where Surgeon A. M. Wilder, U. S. V., removed the plug from the anterior portion of the brain. Death supervened in a few hours after the operation. Case. — Lieutenant Colonel Cornelius W. Tolies, chief quartermaster Middle Military Division, was attacked on the 11th of October, 1864, by a band of guerillas as he was passing through Newtown, Virginia, on his way to the front. Although he surrendentd without resistance, one of the treacherous party, stepping behind the Colonel, shot him in the head. The missile, a pistol ball, penetrated the cranial cavity through the occipital bone at a point midway between the superior angle and the curved line, three-fourths of an inch to the left of the median line, making a clean perforation and lodging in the posterior lobe of the cerebrum one-half inch deep. He was conveyed to Winchester, and placed under the care of Dr. Emanuel, Acting Staff Surgeon U. S. A. This officer states that the wound suppurated well, and caused no pain.; the patient’s mental faculties remained unimpau'ed, and his appetite good, so that a favorable prognosis was granted. On October 22d, the ball was extracted in small fragments. About the end of October, evacuations of the faeces and urine began to occur involuntarily ; on the 31st, there was an entire suppression of the urine, as ascertained by the introduction of the catheter, and the faeces were again discharged involuntarily. On the 4th of November, the vision and hearing became defective. Delirium ensued, and death occurred on November 7th, 1864. Upon removing the calvaria, at the autopsy, the dura mater around the wound was found ecchymosed, and the cavity in the cerebrum, which was about one-half inch deep, filled with purulent and ofiensive pus, and lined with plastic filamentous fibrin. A fragment of bone, about three-fourths of an inch in diameter, was extracted from a point just below. The pia mater had sufiered morbid changes. A sero-purulent fluid w'as found in the inferior and posterior depressions of the lateral ventricles, and likewise in the fourth ventricle, the lining membrane of which cavity had undergone softening, as had also the sheaths of the roots of the seventh, eighth, and ninth pairs of nerves, which were of a greenish hue; the optic commissure was congested. The substance of the encephalon was sound throughout. The semi-lunar lobe of the left lateral hemisphere of the cerebellum was firmly adherent to the tentorium. The case is reported by Acting A'ssistant Surgeon W. L. Hammond. Case. — Private A. A. Watson, Co. B, 48th North Carolina Eegiment, was, on June 7th, 1864, admitted to hospital No. 24, Eichmond, Virginia, with a gunshot fi-acture of the skull. The missile entered at the right protuberance of the frontal bone, passed through and lodged. He was speechless until June 9th. An abscess formed on the back part of the head, which was opened on June 12th, and the ball removed. Slight improvement followed, but in a few days the wound became very offensive. The patient slept nearly all the time until death ensued, June 20th, 1864. The following cases of penetrating gunshot fractures of the head terminated fatally : Case. — Private D. C , Co. D, 10th Pennsylvania Eeserves, aged 26 years, was wounded near Old Church, Virginia, May 30th, 1864, by a conoidal ball, which fractured the anterior inferior angle of the right parietal bone, and lodged in the brain. He was admitted to the hospital, 3d division. Fifth Corps, on the same day, and was transferred to the Stanton Hospital at Washington, on the 4th of June. Several fragments of bones were removed. A cerebral abscess formed, and death ensued on the 11th. The pathological specimen. No. 2682, Sect. I, A. M. !M., is a section of cranium, from which fragments have been removed for a distance of two inches from before backward, and one-half inch in width ; a fragment, half an inch long, remains in situ. The inner table is fractured to a somewhat greater extent, and two small fragments remain, with their free edges slightly depressed. There is caries of the fractured surface, but no distinct attempt at repair. The specimen and history were contributed by Assistant Surgeon G. A. Mursick, U. S. V. Case. — Sergeant George W. Burtiss, Co. G, 173d New York Volunteers, was accidentally wounded, on Januaiy 23d, 1864, by a pistol ball, which fractured the cranium and lodged in the left side of the brain. He became unconscious and was taken to the regimental hospital. Ten minutes after the accident his countenance was livid, pulse slow and full, respiration labored and spasmodic. Some reaction took place now, and he cried out to have his face wiped. He struggled to get up to urinate and begged his attendants to let hhn go out of the tent for that purpose, but he could not pass any urine. In half an hour he relapsed into a quiet state. The pulse continued slow but irregular, and occasionally spasmodic movements of the extremities occurred. The pupils were not affected by strong light. Tlie patient died nine hours after the reception of the injury. At the autopsy two small wounds were found, one incised, about one inch above the left eyebrow. The areolar tissue of the left eyelid and surrounding the wounded parts were infiltrated with blood. Several spiculae of bone and a small scale of lead were lodged in the soft parts near the wound. A circular opening about a half inch in diameter through the external, and three-fourths of an inch through the internal table, was found in the frontal bone about one inch above the left superciliary ridge. Fig. 101 . — Two lateral views of a fragment of a conoidal ball split upon the skull. Spec. 4150, FATAL PENETRATING GUNSHOT FRACTURES OF THE SKULL. 201 Between the skull and dura mater were several spiculae of bone. The left hemisphere of the cerebrum was extensively lacerated through its longitudinal diameter. The bullet was found in the posterior lobe of left hemisphere near the dura mater. Large clots of blood covered tlie left hemisphere and lay at the base of the brain, surrounding the upper extremity of the spinal cord. The case is reported by Surgeon N. W. Leighton, 173d New Yoi’k Volunteers. Case. — Private Anton Lambert, Co. E, 9th Kansas Cavalry, was wounded, in a skirmish with guerillas, near Westport, Missouri, June 17th, 1863, bj' a conoidal ball, which passed through the mastoid process of the right temporal bone, and fractured a part of the petrous portion, at its union with the jugular process of the occipital. On the following day, he was admitted to the hospital at Kansas City, Missouri, and died June 20th, 1863. The autopsy revealed a rupture of the lateral sinus. The ball had glanced forward, destroying the labyrinth ; had passed under the basilar process of the occipital bone, and had lodged in the masseter muscle, near the coronoid process of the lower jaw. Case. — Sergeant G. C— ^ , Co. A, 11th New Jersey Volunteers, aged 26 years, was wounded at the battle of Chancellorsville, May 3d, 1863, by a musket ball, which penetrated the right temporal bone, and lodged deeply in the substance of the brain. He was conveyed to Washington, and on the 7th, was admitted to the Douglas Hospital. Hemiplegia of the left side existed at the time of his admission ; the pupil of the riglit eye was much dilated, and brain substance was protruding from the wound of entrance. Simple dressings were applied to the wound, and expectant treatment was had recourse to; but he died on the 11th of the month. At the autopsy, the missile was found lodged behind the sella Turcica. It was a bullet, with a deep groove containing a fragment of the temporal bone, contributed, with its history, by Acting Assistant Surgeon John O. Smith. Fig. I02.-Round ball lodged in the cerebrum. Sp. 1288, Sect. I, A. M. M. Case. — Private E. G , 18th Indiana Battery, aged 25 years, was accidentally wounded on January 7th, 1865, by a pistol Sail which penetrated the cranium one inch above the superciliary ridge and three- fourths of an inch to the left of the median line. He was sent to Hospital No. 8, at Nashville, in a semi-conscious condition. Digital examination revealed a circular, well defined opening through the os frontis, corresponding with the tegumentary opening. A gum-elastic bougie could be passed two and a half inches in the track of the ball antero-posteriorly through the left hemisphere. Brain substance escaped. On January 9th, the wound of entrance through the scalp was enlarged to promote free discharge of pus ; clots of brain substance continued to escape. On January 10th, the patient talked incoherently, his respiration was slow and sighing, face flushed, and pupils natural. On January 12th, he was unable to speak; coma supervened, and death occui-red .lanuary 14th, 1865. The ball had traversed the whole length of the left hemisphere, its course being easily distinguished by the black, sloughing, ragged appearance of the track, which terminated at the occipital without rupturing the membranes or fracturing the occipital bone. The entire encephalon, with the exception of parts immediately around the track of the missile, presented a normal appearance. The cranial cavity was thoroughly explored, and the brain was cut into small pieces in order to find the ball, but the search was fruitless. The ball must have dropped out of the wound of entrance at some time when the face and head hung lower than the body. On no other theory can the absence of the ball be explained. The pathological specimen is No. 3747, Sect. 1, A. M. M., and was contributed by Assistant Surgeon C. C. Byrne, U. S. A., while the history of the case is reported by Acting Assistant Surgeon H. C. ilay. Case. — Private Alpheus Salisbury, Co. K, 7th Rhode Island Volunteers, was wounded at the battle of Fredericksburg, December 13th, 1862, by a piece of shell, which fractured the skull behind the right ear. On December 18th, he was admitted to Harewood Hospital, Washington, and on January 10th, 1863, was sent to Lovell Hospital, Portsmouth Grove, Rhode Island. He was discharged March 19th, 1363, and died July 2d, 1883, his widow receiving a pension fi-om that date. Doctor William H. Bowen, in a report relative to this case says, that the most prominent symptoms were great pain in the head, frequent vomitings, constipation, and a kind of stupor. The wound in the head had not healed, and on probing it pus and blood were discharged. He learned that several pieces of bone had been taken away since the injury was inflicted. On July 1st, he saw the patient, in consultation with another physician. Pain in the head and vomiting still continued, and there was more perfect unconsciousness. The next morning there was paralysis of the side opposite the wound in the head, with one pui)il contracted while the other was dilated, and he was perfectly comatose. He thinks that the wound was the primary and the original cause of death. Case.— Sergeant William B. Etter, Co. D, 16th Maine Volunteers, aged 26 years, was wounded at Fredericksburg, December 13th, 1862, by a piece of shell, which fi-actured both tables of the cranium at the vertex to the right of the median line. He was admitted to the 2d division. First Corps hospital. Partial paralysis of the left upper and lower extremities, involving the bladder, followed. On December 19th, the patient was transferred to Alexandi ia, and was admitted to the 3d division hospital. Stimulating lotions were applied to the extremities and a catheter was used for several days. He died on January 23d, 1863. The autopsy revealed the external table fissured to the left ear. A fragment of bone, one inch in diameter, was found pressing upon the brain ; smaller fragments had penetrated its substance. The left pleura was covered with extensive and recent adhesions and studded with deposits of lymph and pus. The right lung contained a large number of abscesses. The case is reported by Surgeon E. Bentley, U. S. V. C..V.SE.— Private George Knapji, Co. D, 8th New Hampshire Volunteers, was accidentally wounded on October 29th, 1864, while on picket near Natchez, Mississippi, by a conoidal ball which sdruck the left side of the frontal bone over the superciliary ridge, about one and one-fourth inches to the left of the median line. The missile split ; one-half lodged, the other penetrated the skull and passed deeply into the brain. It is recorded that the missile before wounding this man had passed through the body of a comrade. The patient was sent to hospital at Natchez, where a portion of the ball was removed. Coma, stertorous breathing, vomiting, and involuntary evacuations followed ; and death occurred October 30th, 1864, twelve hours after rece[)tion of injury. The autopsy revealed an extensive depressed fracture at scat of wound and a line of fracture extending across the parietal bone to the lambdoid suture. One-half of the ball was found imbedded in the substance of the brain just above the sella Turcica. The left lateral ventricle contained a large coagulum extending into the track of the ball. 26 202 WOUNDS AND INJURIES OF THE HEAD, Case. — Corporal Gardner Gaylord, Co. B, IGth Massachusetts Volunteers, was wounded at the battle of Bull Run, Virginia, August 30th, 1862, by a conoidal ball which penetrated the cranium just above the right frontal eminence, causing a stellate fracture witli cleanly cut edges. On September 1st he w:is admitted to the Judiciary Square Hospital, being perfectly conscious. All his functions remained normal ; he was able to help himself and com|)lained of no pain. On September 3d he became comatose, and died September 5th, 1862. At the autopsy the ball was found to have entered the anterior lobe of the right hemisphere, carrying with it fragments of botie and traversing the brain substance nearly the full extent of the hemisphere. At the point of entrance there was an abscess the size of a walnut, and the track of the ball was filled with pus. A small quantity was also found in the left ventricle. The case is reported by'Surgeon Charles Page, U. S. A. Case. — Private J. D , Co. G, 5th Tennessee Regiment, aged 30 years, was wounded at the battle of Tunnel Hill, Georgia, April 30th, 1864, by a musket ball which fractured the frontal bone, traversed the brain and lodged. He was conveyed to Nashville, and on the 5th of May was admitted into hospital No. 1. Brain matter, yielding a thin, greenish, and fetid dis- charge, protruded from the wound, which evidently was of considerable extent. An examination of the wound w'as made and it was ascertained that a plate of the central portion of the frontal bone had been displaced so as to project half an inch or so, thus allowing free protrusion of the cerebral substance. The surrounding soft parts were of course much inflamed and swollen. The patient was perfectly rational and would answer questions promptly, though he had no inclination to converse, and if left undisturbed, ^vould sleep the greater part of the time. The pulse was alternately strong and intermittent. The digestive functions remained undisturbed. The patient did not complain of much pain, and could stand and walk. The treatment was expectant ; but the patient gradually sunk into a comatose state, though when fully aroused he would recognize the attendants, and make his desires known, as late as May 14th. Death took place on May 15th, 1864. At the autopsy the displaced fragment of the frontal bone was found to measure four and a half inches in diameter. A fissure passed downward separating a part of the great ala of-the sphenoid and the squamous portion of the temporal bone. The missile was found in the vicinity of the left great wing of the sphenoid against which it had struck, the point of contact being evident by discoloration as well as by a slight fissure of the vitreous table. The pathological specimen with history was contributed by Surgeon R. L. Stanford, U. S. V. It is numbered 3358 in the surgical section of the museum. Case. — Captain W. E. Tucker, Co. B, 67th Pennsylvania Volunteers, was wounded at Annapolis, Maryland, October 29th, 1862, by a conoidal ball which fractured and depressed both tables of the os frontis one and a half inches above the left superciliary ridge and penetrated the brain. On the same day he was admitted to the 1st division hospital in a state of stupor with respiration labored, pupils contracted, and pulse full and slow. Upon probing the wound brain matter exuded. The treat- ment was expectant. Full consciousness wms restored on the morning of the 30th, so that when aroused he readily recognized his friends and answered questions correctly. He soon relapsed into tlie former comatose condition. On the following day two small fragments of bone were discharged from the wound. On the morning of November 1st, a decided febrile action w'as established. The pulse rose from 55 to 90 and the skin became hot and dry. Tincture of aconite was administered in five-drop doses every two hours, and twelve hours afterward the dose was increased to ten drops, but failed to effect a reduction of the pulse, which had reached 160 on the 2d of November, when death occurred. No deliilum existed at any time during the progress of the case. At the autopsy a small, smooth perforation was found to the left of the median line about three-eighths of an inch in diameter. The injury to the inner table wms more extensive, covering three-fourths of an incli in diameter. Fragments of the inner table were driven into the anterior lobe of the left hemis])here and softening existed in their immediate vicinity. The missile, which w’eighed 32 grains, w'as traced diagonally downward through the corpus callosum to its place of lodgment beneath the ])osterior lobe of the light hemisjdiere. A large clot of blood surrounded the orifice in the cranium and purulent spots were present in the surface of the cerebrum. The lateral ventricle was filled with blood. The case is reported by Assistant Surgeon James W. Pettinos, 67th Pennsylvania Volunteers. Case. — Private Thomas Urch, Co. F, 211th Pennsylvania Volunteers, was wounded before Petersburg, Virginia, April 2d, 1835, by a conoidal ball which entered the brain through the frontal bone one and a half inches above the right eye. On the same day he was admitted to the hospital of the 3d division. Ninth Corps, and thence was conveyed to Armory Square Hospital, at Washington, which he entered on Ajiril 10th. An attempt was made on the following day to remove the ball, but was unsuccessful. Death from apoplexy occurred April 14th, 1865. Case. — Private George Deal, Co. D, 148th New York Volunteers, aged 23 years, was wounded at the battle of Coal Harbor, Virginia, June 3d, 1864, by a conoidal musket ball, which penetrated the cranium and passed through the anterior portion of the cerebrum. He was admitted to the Eighteenth Corps Field Hospital, and on the*7th of June transferred to the Carver Hospital, Washington, D. C. The particulars in the progress of the case are not known. Death took place on the 8th of June, 1864. Case. — Sergeant Alexander E , Co. B, 56th North Carolina Regiment, aged 30 years, was wounded at Petersburg, March 2Sth, 1865, by a conoidal ball, which entered the body of the left malar bone, producing a comminuted fracture, passed from left to right through the orbit, fracturing the ethmoid bone, and lodged in the anterior portion of the base of brain on the right side. He "was conveyed to a field hospital, and on Mai’ch 30th was admitted to Lincoln Hospital, Washington, being nearly comatose. The probe could be passed into the braiu. Death occurred on April 2d, 1865, from exhaustion and congestion. The autopsy revealed the course of the ball as above stated. The j)athological specimen is No. 85, Sect. I, A. M. M., and consists of nine fragments, chiefly from the malar bones, and the ball, separated into two parts. The specimen, with the history, was contributed by Acting Assistant Surgeon T. P. Arthur. Case. — Sergeant Charles B. Hummell, Co. D, 127th I’enusylvania Volunteers, aged 22 years, was wounded at the battle of Fredericksburg, Virginia, May 1, 1863, by a spherical case-shot which penetrated the right parietal bone near the junction of the sagittal and coronal sutui’cs. On the morning of the 6th, he was conveyed by steamer to Wtishington, and was admitted to the FATAL PENETRATIJv'G GUNSHOT FEACTUEES OF THE SKITLI,. 203 Stanton Hospital, in a stato ol’ uiieonscioiisiioss, snii'wiug from the shock of injury ; his pulse was one humlreil and sixty and very feeble. By the afternoon of th.at day he had rallied considerably, thongh he still remained insensible. No paralysus of any part of the body could be detected. He lay upon his back, apparently sleeping, his respiration being ])erfectly natural. During the examination of the pupils, which were found somewhat contracted, though still sj'mmetrical, he exhibited manifestations of con- sciousness by offering some resistance. A probe was readily passed a considerable distance along the track of the missile into the brain substance. Very little haemorrhage from the wound occurred. The patient swallowed without difficulty and passed his urine involuntarily. After shaving the head a bag of ice was applied; a stimulating injection was then employed, which acted well, and nutriment was given in the form of beef tea. The next morning the pulse was one hundred and fourteen and some- what stronger; the pupils were natural in size, and contracted readily under the action of light. He readily Hexed and extended his legs, raised his hands to his head, rubbed his eyes, which he kept closed, stretched and yawned like one awaking from a sound sleep, and endeavored to remove the ice bag. He manifested dislike to beef tea and seemed to recognize the souml of his name when addressed, but took no notice of surrounding objects. ■ The enema was repeated. On the morning of the 9th. the pidse had risen to one hundred and thirty, with further dilation of the right pupil. Half grain doses of calomel, with one-eighth grain of ipecac, were now given every eighth hour. On the 10th, stupor became profound, with paralysis of the right buccinator muscle. No other face muscles were involved and there were no convulsions or paralysis. On the 11th there was full dihitation of the right pupil, the left remaining natural. The respiration, still without stertoi-, was greatly increased in frequency, the diaphragm assisting but little in the breathing. The power of deglutition was lost and the right arm was partially paralyzed. The enema was repeated but the patient continued to sink, and died at eight P. Ji. on the 11th of May. At the autopsy, some fragments of bone were found at-4he-waund of entrance. On removing the calvaria, a large quantity of serum, slightly tinged with blood, escaped froln the cavity. The missile had passed downward, backward, and to the left side, into the left cerebral hemis{)here. Several small pieces of bone, a piece of scalp, and some liair, were distributed along the track, around which, for the distance of half an inch; the bi’ain was softened by inflammation. A large clot of blood lay along the right side of the falx cerebri. The pathological specimen. No. 1137, Sect. 1, A. M. M., showing five fragments of bone, with a round bullet, removed at the autopsy, was contributed, with the history, by Surgeon John A. Lidell, U. S. V. Case. — Lieutenant John Harris, of McIntyre’s Command, C. S. A., aged 27 years, was wounded in action near Helena, Arkansas, about the middle of June, 18ti4, by a conoidal musket ball which detached the riglit ear and entered the cranial cavity at the junction of the parietal and occipital bones. He was admitted on June 24th into the general hospital at Helena. The wound soon became gangrenous, and death resulted on July 1st, 18fi4. No further particulars are recorded. Case. — Private Alexander Johnson, Co. A, 102d U. S. Colored Troops, received at the battle of Pocotaligo, South Caro- lina, December 9lh, 18(14, a penetrating fracture of the cranium from a missile which entered at the right orbit and involved the brain. He was conveyed by hospital steamer to Beaufort and admitted into the general hospital on the 12th. The wound was dressed in the usual manner. On the 14th he Avas transferred to division hospital No. 2, at the same place. Death resulted on December 22d, 1864. Case. — Private John .Johnson, Co. H, 72d Indiana Volunteers, was Avounded in the head in a skirmish at \Ve.st Point, Mississippi, February 22d, 1864, by a musket ball Avhich entered the cranial cavity on the left side and lodged in the substance of the brain. He Avas conveyed to Memphis, Tennessee, and admitted on the 27th into the Washington Hospital. Meningitis and coma supervened, and death resulted on the 11th of March, 1864. At the autopsy the ball Avas found, but the exact jilace of lodgment is not stated. Case. — Captain John K. Lamrie, Co. D, 6th Wisconsin Volunteers, aged 28 years, Avas Avounded at Hatcher’s Eun, Vir- ginia, February 6th, 183.’3, by a conoidal ball, Avhich penetrated the cranium. He Avas .admitted to hospital 3d division. Fifth Corps, and on February7th, sent to hospital of Fifth Corps at City Point. There was evidently compression of brain from extra- vasation of blood. He died February 18th, 188.'). At the .autojisy the greater longitudinal sinus Avas found jteiforated, and fr.ag- ments of bone Avere lying loose upon the brain. Abscesses had formed in the superior and internal portion of each hemisphere and Avere in a sujjpurating condition. Case. — Corporal IF. F. Lancaster, Co. F, 3d Virginia Regiment, aged 24 years, Avas AVounded at the battle of Gettysburg, July 1st, 1863, by a musket ball Avhich penetrated the squamous portion of the right temporal bone, just above and anterior to the meatus auditorius and lodged. 'The missile was extracted on the field and the p.atient Avas conveyed to the Seminary Hos- pital, Avhere he remained until the 20th of the month. He Avas then sent to West’s Building Hospital, Baltimore, being at the time irritable, as his Avound Avas painfid, and his sleep at night disturbed. Cold-Avater dressings and expectant treatment Avere used. On the 1st of August short periods of delirium occurred, Avith quick, sm.all pulse, which Avas folloAved by obstinate diarrhoea. By the 4th, delirium had hecome constant, terminating five days later in a state of p.artial stupor. Insensibility fol- loAved, on the morning of the 10th; his respiration becoming stertorous, pulse frequent and Aveak; and death occurred at five o’clock in the afternoon. At the autopsy, the portions of the squ.amous bone immediately surrounding the upper part of the per- foration Avere found dejtressed nearly a fourth of an inch. The parietal, sphenoid, and frontal bones Avere also involved in the fracture, Avhich measured three and a half by tAVo inches. In the immediate vicinity of the fragments disorg.aniz UJ 1 - < D. PERFORATING GUNSHOT FRACTURES OF THE SKULL. 207 and proper guard for the delicate tissues. Early in December, he was able to sit up and walk about the wards, and was never afterwards confined to the bed. From this time the fungus commenced to decrease in size, and continued to do so until shortly before his discharge from the service, January 2Gth, 1863, when it liad shrunk below the level of the skull, and both openings had been well covered by cicatricial tissue. During the progress of the case numermts spiculse of bone were removed as they became detached. The constitutional treatment consisted in paying strict attention to the diet, and exhibiting saline cathartics and turpentine injections as the symptoms seemed to call for. When the soldier left my hands he complained of no inconvenience whatever with the exception of the occasional attack of giddiness, and the fact that he could not see a small object when placed in a j)osition directly on a level and on a middle line between the eyes. Both which defects, I consider, will diminish with time until lost. Shortly before the patient’s discharge from Mount Pleasant, an excellent picture of the aspect of the injury at that time was made in water color, under the direction of Surgeon J. 11. Briuton, U. S. V., who was then in charge of the Division of Surgical Records of the Surgeon General’s Office, and had secured the services of an artist, Mr. Stanch, whose admirable draw- ing and coloring have furnished some of the best illustrations of this book. The figure on the right of the chromo-lithograph opposite is a good copy of Mr. Stauch’s water-color diawing. I take the following memorandum of the case from one of the mem- orandum books turned over to me by Dr. Briuton : 'Gunshot wound of head: The picture of this case was taken at the Surgeon General’s Office, whither the man came us an orderly, or on an errand. He was perfectly well. A small carnified cerebral hernia existed at the exit wound, which was healing rapidly. The ball went into cavity of the skull and emerged. No symptoms existed at all, when the patient’s portrait was taken. The wound was then some three or four months old. The history of this case, which I took at the time, has been unfortunately mislaid.’” After this we have the history of the case taken up by the pen- sion examining surgeons. The patient went to Newcastle, Delaware, and was pensioned at four dollars a month, until June. 1869, when his pension was increased to eight dollars a month. Dr. D. W. Maull reports at this date, that there was a loss of substance of the skull two inches wide and three inches long, leaving a large depression, covered only by the integuments of the cranium. "Through this can be seen at all times the pulsations of the brain. About the cavity the bone is ridged by the union of the fractured margins. There is almost constant dull pain, some loss of hearing, and the sight of the right eye is impaired.” Dr. Maidl regarded the disability as total. Yet the man worked afterw.ards in an iron foundry as puddler. On December 20th, 1870, this patient was examined by Doctors William Thomson and W. W. Keen of Philadelphia, who have published an interesting account' of his condition at that time, with a photograph, of which a reduced copy is given in the annexed wood- cut, (Fig. 103.) I make the following quotations from this paper: “His memory is quite good, but by no means so good as before the injui-y. He is rather easier bothered and confused, and more irritable than formerly. The sight of his right eye, he thinks, is poor. Whisky affects him as usual. Sexual power undiminished. He has no paralysis. The wound of entrance * * * is marked by a slight depression in the bone, the wound of exit bj' a hollow two and a half by two inches, and one inch deep. No bone lias closed this opening, but the scalp and hair dip down into the hollow. The arterial pulsations are barely perceptible. When recum- bent the hollow is gradually obliterated and replaced, in about one minute, by a rounded protuberance. To prevent pain during this change, he supports the parts with his hand. When he coughs, even with moderate force, the depressed scalp instantly bulges up in a cone, which nearly reaches the general level of the skull and obliterates the depression, and then as suddenly subsides.” Drs. Keen and Thomson observe that “the complete recovery from paralysis, (as evinced by his subsequent severe labor,) and the almost enti-e restoration of his mental faculties, are remarkable, especially in view of the probable deep lesion of the brain, both by the primary injury and the subsequent fungus cerebri.” They comment also upon "the rapid changes in the state of the cranial contents, due to any change of posi- tion, to coughing, etc., as evinced by the efifacement of the depression at the wound of exit.” The authors also regard the case as of value in throwing light upon the probable anatomy of the optic commissure. Their discussion on this point is given in a foot-note.^ Fig. 106. — Cicatrix of .a gunshot perforation of the skull, eiglit years after tlie reception of the wound. [From a pliotograph.] ^Photographic Rcritm of Medicine and Surgery. Vol. 1, No. 3, p. 26. Philadelphia, February, 1871. .1. 15. Lippincott Co. * "Wollaston, (Phil. Trans. 1821, p. 3JJ,) reasoning from two attacks of transient hemiopsia, occurring in himself, and other cases in friends, appears to have been the first to point out the semi-deoussation of the optic nerves at the chiasm. Longet (Traitfi de Phys., 2d cd. ii, 476) seems to assent to the explanation, though he refers to cases of perfect sight in which it is asserted no chiasm existed ; and in his Traite d'Anat. et de I’hys. du Syst. Nerv., p. 666, he gives cases of perfect sight in both eyes, in spite of nnil.ateral ccrehral atrophy or traumatic lesion. Von Graefc (.Vrehiv, ii, 286) assents cordially to Wollaston's view, admitting that he proposes nothing new, but that which is far too little knoivn. Hubert Airy, (On a Distinct Form of Transient Hemiopsia, Proc. Hoy. .Soc., Feb. 17th, 1870, in “ Nature,” i. 111,) after a careful examination of preceding writers, also supports it ; and the experiments of I.aborde and i.even, (Med. Gaz., Nov. 5th, 1870 ; from Gaz. Jled. de I’aris.) who found atrophy of the right optic nerve following tlie removal of the superficial right cerebral convolutions, and without any apparent irritative processes, would also point in the same direction. In our own case, the point to which we desire to call special attention is tlie rigid optical e,xamination of the region between the porus opticus and the macula lutea. The semidecussation of the nen-es .at ttie chiasm being admitted, it would naturally be supposed that the fibres a from the left tract would supply the left retina from the porus opticus towards a' ; but our extimina- tion show-s tlmt it suppiies /css than this. viz. ; only that ptirt of the retina from c to a' ; while in the right eye the fibres b, instead of supplying the retina from the porus opticus to 6', sii]'ply more than this, viz. ; that piirt of the retina from c' to 6'. In other words the fibres a and b of the left optic tract su]>ply, matlicmatically, the left halves of the two retinae from c to a' and c' to ?/, and the rigid tract tlie rigid halves. As to the cerebral scat of the sense of vision, relations of tlio optic commissure and the amount and depth of tlie injury to the brain arc too uncertain, perhaps, to warrant us in venturing on any specu- lations as to its locality.” Fig. 107. — Diagram indicating tlie 208 WOUNDS AND INJURIES OF THE HEAD Case.— Private Abraham D. Myers, Co. K, 4th New York Cavalry, aged 21 years, was wounded in an engagement near Charlestown, Virginia, August 28th, 1864, by a conoidal musket ball, winch penetrated the frontal bone just above the right eye, and passing downward through the orbit emerged near the right ear. On the following day he was admitted to the general hos- pital at Sandy Hook, Maryland. On September 4th, he was sent to the Jarvis Hospital at Baltimore, and on the 12th, was trans- ferred to the !Mower Hospital, Philadelphia. The treatment seems to have been of a general character. He I’ecovei'ed, and on February 13th, 1865, was transferred to the Veteran Reserve Corps. This patient is not a pensioner. In the following cases of perforation of the skull by musket halls, the patients sur- vived, though totally and permanently disabled : Case. — Private Hugh Collins, Co. I, 26th New York Volunteers, was wounded at Antietam, September 17th, 1862, by a conoidal ball, which entered the cranium just above the right eye and lodged in the left side of the neck, four inches below the ear. The ball was removed, and the patient was admitted to the field hospital at Smoketown, Maryland, October 8th, 1862. On December 20th, he was discharged the service. On February 18th, 1833, he was examined for a pension by Pension Examiner H. B. Day. Partial amaurosis of both eyes existed, otherwise the man enjoyed good health. Subsequent information states that this man was unable to work, and that his sight was impaired. His disability is rated total and permanent. Case. — Piivate John H. Stallman, Co. A, 4th Pennsylvania Cavalry, aged 21 years, was admitted to the National Hos- pital at Baltimore, from Sandy Hook, IMaryland, September 8th, 1864, having been wounded at Wincbester, Virginia, July 24th, 1864, by a musket ball, which entered at the right temple and emerged at the opposite side of the head. When admitted he was stupid and almost comatose, in which condition he remained for several weeks. He finally recovered so fiir as to be fit for light duty, but being subsequently seized with a spasm was again placed under treatment. On December 10th, 1864, he was trans- ferred to Cuyler Hospital, Philadelphia. On admission, the wounds were entirely healed; his bowels were constipated, and he suffered from almost constant nausea. His pulse was slow and feeble; tongue slightly coated with a whitish fur, the tip and edges remaining red; his pupils were equal and constantly dilated. He had no strabismus. He stated that he had purulent dis- charges from his right ear, attended with pain. His mental faculties w'ere slow and uncertain and his memory impaired, but he had no hallucinations or mental aberrations. While in this hospital he had one slight spasm. On May 10th, 1865, he was ti'ans- ferred to the Mower Hospital, Philadelphia, whence he was discharged the service May 23d, 1865, and subsequently pensioned. On June 24th, 1865, Pension Examiner W. J. McKnight reports: “It is beyond my power to tell the extent of the injury. I only wonder that the boy lives.” He rates his disability as total. Case. — Private William H. Haggart, Co. G, 92d Illinois Volunteers, aged 17 years, was wounded at Powder Springs, Georgia, October 3d, 1864, by a conoidal musket ball, which struck the left side of the head, and passing through carried away.a large fragment of the left half of the occipital bone. He became insensible and lost more than an ounce of cerebrum, leavmg bare the meningeal artery. For several weeks he was treated in the hospital at Marietta, and on November 10th, was sent, via Chat- tanooga, to Nashville, Tennessee, where he was admitted to Hospital No. 2, on November 12th. He was furloughed on Novem- ber 10th, and afterward was admitted to the hospital at Mound City, Illinois. He was discharged on April 20th, 1865. The pupils of both eyes were dilated, causing dimness of vision, so that he could only read very coarse print. The case is reported by Acting Assistant Surgeon J. K. Fay. A communication from the Commissioner of Pensions dated January 21st, 1870, states that the man was a pensioner until November 19th, 1868, when he died. Case. — Private Joshua F. Lock, Co. E, 15th Iowa Volunteers, aged 21 yejirs, was wounded near Atlanta, Georgia, August llth, 1864, by a conoidal musket ball, which caused a perforating fracture of the base of the cranium. On the same day he was admitted to the hospital of the 4th division. Seventeenth Corps ; on the 14th, was sent to the Seventeenth Corps hospital, and on September 20th, 1864, was furloughed. On November 22d, he was admitted to the hospital at Keokuk, Iowa. Simple dressings only were applied to the wound. He was discharged the service August 2oth, 186.5, and pensioned. On August 28th, 1865, Pen- sion Examiner H. F. Cleaver states that there was partial hemiplegia of the right side, and rates the disability total. Case. — Sergeant James M. Woodman, Troop E, 1st District of Columbia Cavalry, was wounded in the engagement at Weldon Railroad, Virginia, August 23d, 1864, by a gunshot missile, which entered just above the left frontal eminence and emerged at a point one inch behind the upper margin of the right ear. He was unconscious for several hours, and for three months was delirious during the night. He was examined on P^ebruary 2d, 1865, by Pension Examiner R. K. Jones. At the wound of entrance was a cutaneous scar, but the bone was not depressed. At the wound of exit, eight small fragments of bone had been discharged, leaving a depression one-third to one-half inch deep. Both scars, esjjecially the latter, were sensitive to pressure. The organs of special sense and the intellect were unimpaired. At night, and when he stooped or was exposed to heat, he had pain in his head. He was discharged the service August 10th, 1865, and pensioned. On August 7th, 1867, Pen- sion Examiner John Benson reported that small portions of bone had exfoliated. The patient suffered considerably from dizzi- ness and sharp pains in the head, and was unable to perform much labor. He had been subject to great suffering and pain ever since he was wounded. His disability is rated total and permanent. Case. — Private Charles C. Trotman, Co. H, 9th Mississippi Infantry, aged 17 years, was wounded at the siege of Atlanta, Georgia, August 30th, 1864, by a ball, which entered the forehead just above the left eye, and emerged beliind the right ear. He was retired by an examining board on January 3d, 1865. The vision of both eyes was affected, and he was permanently disabled. Case. — Lieutenant W. H. Coward, Co. F, 7th Arkansas Regiment, aged 22 years, was w'ounded in an engagement at Jonesboro’, Georgia, September 1st, 1864, by a conoidal musket ball, wliich entered the cranium one inch above the mastoid process and presented itself on the opposite side, where the cerebral matter left no doubt as to tbe fact that the brain was injured. PERFORATING GUNSHOT FRACTURES OF THE SKULL. 209 On the following day, he was admitted to the hospital of the 2d division, Fourteenth Corps, being perfectly unconscious, with stertorous breathifig. Toward evening, he became conscious and restless, complaining of loss of vision and inability to raise his head. Toward midnight he commenced to scream, ami for three weeks did so incessantly, even during his moments of sleep. On September 20th, he suddenly became composed and quiet, and answered questions coherently. The left side for some daj’s seemed paralyzed, as he could not use his hand or leg. The face was drawn to the light, and he seemed to have some difficulty in swallowing; his secretions were natural, and he had constant priapism, with seminal emissions. All these symptoms, how- ever, became gradually better; but as soon as he became able to move about, he seemed unable to guide his movements, and the power of will over motion seemed lost. Hut he rapidly improved. During the progress of healing, several spiculm of bone came away. About the seventh week all discharge from the wound had ceased. The patient was transferred to Nashville on October 30th, 183-1. The pupil of the left eye seemed permanently dilated and intolerant of light. On December 8th, 18G4, he was sent to the Provost Marshal for exchange. The case is reported by Surgeon Edward Batweli, 14th Michigan Volunteers. Cask. — Private Eugene Plumly, Co. L, 8th New York Heavy Artillery, aged 23 years, was wounded at I’etersburg, Vir- ginia, June 16th, 1834, by a conoidal musket ball, wliicli entered at the inner angle of the left eye, passed through the brain substance and emerged behind the left ear. He was admitted, on the same day, to the Second Corps hospital, and thence was conveyed to the Lovell Hospital in Rhode Island, where he arrived on June 26th. He remained under treatment at Portsmouth Grove until the 22d of August, when he was transferred to the Ira Harris Hospital, Albany, New York, the wound being still open. The treatment consisted chiefly in the dressings of the wound, which had cicatrized by the 22d of December. His gen- eral health being good at that date, he was discharged the service and pensioned, the vision of the left eye being obscured. On March 7th, 1867, Pension Examiner John I’ost reported that there was a discharge of pus from the orifice of entrance of the ball and through the right nostril and upper part of the |iosterior nasal cavity into the mouth. There was constant headache; he could not stoop without becoming dizzy, and his eye-sight was imperfect. At night, pus ran into his mouth so that lie was often obliged to rise and cleanse his throat in order to sleep. His disability is rated total and permanent. Case. — Private James R. Gailey, Co. F, 67th Pennsylvania Volunteers, aged 37 years, was wounded in an engagement at Sailors’ Creek, Virginia, April 6th, 1835, by a conoidal ball, which entered the left external ear and mastoid process of the temporal bone, passed obliquely thi'ough the left lobe of the cerebrum and emerged at the centre of the occiput. He was admitted to the hospital of the 1st division, Sixth Corps, on the same day ; thence was sent, via City Point, to the Carver Hospital, Wash- ington, which he entered May 14th, 1865. Simple dressings only were applied to the wound. He was discharged from service on July 15th, 1865, with total deafness of the left ear, and was pensioned, his disability being rated total and temporary. Case. — Private Samuel P. Starrett, Co. I, 1st Michigan Volunteers, was shot through the head at Gaines’s Mill, Virginia, June 27 th, 1862. The missile passed from temple to temple, causing the loss of both eyes. He was taken on board the St earner Vanderbilt, and on July 24th, was admitted to DeCamp Hospital, New York Harbor, where he was discharged the service on September 29th, 1862, and pensioned, his disability being rated total. Case. — Private Robert Elliott, Co. E, H9th Pennsylvania Volunteers, aged 39 year.s, was wounded at the battle of Wil- derness, Virginia, May 6th, 1864, by a conoidal ball, which entered at the occij)ital bone and escaped under the right eye. He was immediately admitted to the 1st division. Sixth Corps, hospital, and on May 27th, was conveyed to the 2d Division Hospital, Alexandria, Virginia. On J une 20th, he was transferred to the hospit.al at Chester, Pennsylvania. Partial j)ara]ysis of the lowei' extremities had occurred. On March 20th, 1865, he was sent to the Turner’s Lane Hospital, Philadely)hia, and was discharged from service on August 29th, and pensioned. On September llthj 1836, Pension Examiner M. G. Emanuel rej>orted that his disabiUty then consisted in partial paralysis of both lower extremities, imperfect vision, disturbance of the mental faculties, and severe pain in the head. In 1867, his disability was rated total and permanent. Case. — Private Samuel Caldwell, Co. H, 16th United States Infantry, was wounded at the battle of Stones River, Tennes- see, .January 3d, 1863, by a round musket ball, which entered the skull about the middle of the left temporal fossa and emerged at precisely the same point on the opposite side. After remaining on the field forty-eight hours, he was removed to a field hos- ])ital. Inflammation extended over the entire upper part of his face, his eyes being closed and exceedingly painfid; the head and face were much swollen. Under simple antiphlogistic treatment the case rapidly improved. By the 13th, all violent pain and inflammation had subsided. Several spiculae of bone were removed, and all accessible sharp points of the fractured skull wei’e broken off. About this time, the patient averred that he could discern light with one of his eyes. The wounds closed with healthy granulation, and the case was progressing finely on the 17th, when he was sent to Hospital No. 12, Nashville, Tennessee. He was discharged the service March 14th, 1863, by reason of total blindness, and was pensioned, his disability being rated total and permanent. The case is reported by Surgeon John M. Todd, 65th Ohio Volunteers. In the foregoing fourteen cases, in which the patients survived gunshot perforations of the cranium, the disabilities resulting were regarded by the pension examining surgeons as total and permanent; “total,” in the classihcation of the Pension Bureau, implying inca- pacity to earn a livelihood by either physical or mental exertion. Vision was destroyed in two instances, and more or less impaired in seven others. Complete deafness resulted in one case; hemiplegia in one case, paraplegia in another, and local paralysis in three others; and nearly all of the patients suffered from vertigo, headache, defective memory, and various forms of impairment of the mental faculties. The reports are not sufficiently detailed to 27 210 WOUNDS AND INJURIES OF THE HEAD, permit a more minute analysis of the results of the extended lesions of the brain, which co-existed with the fractures, in tliis series of cases. The re})orts of a few of the fatal cases of perforating fractures emljrace some particu- lars of interest. The following nine patients were under treatment for periods varying from two hours to four months: Case. — S ergeant Ij. O. Blanding, U. S. Signal Corps, aged 35 years, was wounded in action near Nasliville, Tennessee, April lltli, 18t5;J, by a musket ball, which entered near the centre of the left superciliary ridge and emerged just outside of the external angular process of the frontal bone. Only little hteinorrhage occurred, but he immediately became insensible, and was conveyed to Hospital No. t) at Nashville. An exidoration of the wound revealed a comminution of the superciliary ridge and of the orbital jdate. About a teaspoonful of cerebral matter had been scooped out by the mi.ssile. The patient never reacted ; he remained in a comatose condition until his death, April Kith, 18()‘J, forty-eight hours aftei’ the reception of the injury. The his- tory of the case was contributed by Surgeon Eben Swift, U. S. A. Case. — 1‘rivate John Nulty, Co. C, 28th Massachusetts Volunteer.s, aged 23 years, W'as wounded at the battle of Antietam, Maryland, September 17th, 1862, by a conoidal musket ball, which entered the light zygomatic region anterior to the meatus anditorius, passed through the internal ear and mastoid jirocess of the temjxu-al bone, and emerged two and a half inches directly behind the meatus. He was admitted to the Locust Spring Hospital, where, in the course of treatment, two small pieces of bone were discharged from the meatus and one from the anterior wound. The wound of exit had nearly healed at the time of his transfer to Camp 1! Hospital at Frederick, Maryland, December bth, 1862, but the anterior wound was discharging somewhat. The power of hearing in the right ear was destroyed, and the patient's vision was impaired. After his removal to Frederick he failed gradually, and died on January 20th, 1863. The case is reported by Surgeon T. 11. Sipiire, H'Jth New York Volunteers. Case. — I’rivate .1. J. Frazier, Co. D, 3d Arkansas Ivegiment, was wounded in an engagement on the Williamsburg Road, Virginia, October 27th, 1864, by a conoidal musket ball, which entered one inch to the right of the occipital protuberance, jiassed laterally and a little downward, and emerged one inch to the letl of the occipital i)rotuberance. On October2yth, he was admitteosterior portion a second fissure traversed the right parietal to the centre of the occipital bone. Lines of fractures traversed the right supra-orbital arch, the nasal process of the right superior maxillary, and the base of the mastoid process of the right temporal. The pathological specitnen is quite accu- rately figured in the accompanying w-ood-ent, (Fig. 108.) It was con- tributed, with the history of the case, by Surgeon ,T. II. Beach, 24th Michigan Volunteers. The next case furnishes the best example contained in the Army Medical Museum of diastasis of the cranial bones from external violence. Almost every suture is widely separated : Case. — X , an unknown Confederate, was brought into Lincoln Hospital on July 17th, 1864, in an ambulance train- convening the wounded, abandoned by General Early, in front of Fort Stevens. According to the official rej-xjrts, the Confederates retired from befoi-e Washington on the night of July 12th. The stretchcr-bearer.s reported that this man was found nearly three miles north of Fort Stevens, unconscious and unable to articulate, with a terrible wound over the vei-tex, and that near by him was the huge fragment of shell supposed to have inflicted the injury, and to have been fired from one of the eleven-inch guns at Fort Stevens. It appears .almost incredible that the patient could have survived so long. He died two hours after his admission to hospital. On the following day an autopsy was made. Over the anterior snperior angle of the left parietal bone there was an extended scalp wound. On retlectiug the scalp, multiple depressed fractures of the vault of the cranium came into view. 4'lie point of greatest depression is an inch to the left of the median line, near the coi-onal suture. The depressed fragments measure from before backw-ard two inches, and from right to left three inches, .and involve both parietals and the osfrontiti. A fissure runs through the squamous portion of the left temporal, and all the sutures of tliis bone are separated. The autopsy was made and the specimen was forwarded by Acting Assistant Surgeon Henry M. Dean. It is figured in the adjacent wood-cut, and much better in the Surgical Photograph Series’ of the Army Medical Museum. A yet more remarkable case is reported from Lincoln Hospital. The patient survived a fortnight : Case. — Private William W. Howell, Co. G, llth Pennsylvania Res('rves, was wmtmded at the battle of Fredericksburg, Virginia, December 13th, 1832, by a shell, which fractured .and tore aw.ay nearly all of the left parietal bone. Though in .a state of stupor, he was able to sw-allow food and stimulants. Ho was treahal at a field hospital for nine days, and then was conveyed, on a hospit.al transport steamer, to Washington, .and admitted to Lincoln Hospital on December 23d, .at which time about omo third of the left cerebr.al homis[)here had sloughed. Nearly all the brain sloughed away liefore his death, which occurred on December 26th, 1862. Surgeon Henry Bryant, U. S. V'., recorded tin? case. Fio. too, — Ci-animn fractured by a large fragment of slieU. .Vpcc. 2871, Sect I, A. M. M. Fig. 108. — Cranium fractm-ed by a fragment of sbcll. fipec. 831, Sect. I, A. M. M. ' Photnyraphs nf Surgical Cases aa-l Specimens. I’repared, riy direction of the .Surgeon fleneral, by lirevet Lieutenant Colonel George A. Otis, Assistant .Surgeon, U. S. A. Wa-sliington. 1800. .O Vols., Quarto, Vol. I, Case 3. 214 WOUNDS AND INJURIES OP THE HEAD The specimen represented in the sul)joine(l wood-cut, (Fia. 110,) is from a soldier who survived liis injury tor a tew liours only, and who was left on the battle field; Cask. — A soldier of General Longstreet’s Corps was killed in a charge upon one of the Union hatteries, in the second battle of Manassas, August 29th, 1802, by a grapeshot, at short range. The cranium was ])icked up, a year subsequently, by Surgeon F. W(»lfe, 39th New York Volunteers, under an abatis near the stone bridge over Bull Run. The missile entered the lett jiarietal near the lainhdoidal suture, and made its exit through the squamous portion of the temporal. It is erroneously stated in the CdUdof/ue of the SiirijicaJ iSeelion of the Army Alediral Museum (p. 30), that the fracture was intlicted, “ pr(d)ahly by a musket hall.” The j)robabilities ai’e that the missile was a grajieshot, as suggested by the collector, who had good reasons, apai't from the ajipearance of the injured skull, for his o])inion. It has been supposed that this skull presented an examjjle of fracture by coufre-rotip, a subject to be discussed hereafter. Tliere are, undoubtedly, fissures of the great wing of the sphenoid, and of the frontal, before and behind the right external angular process of the frontal — fissures unconnected with the lesions on the left side of the skull; and the right orbital jdate i.s slightly depres.sed and a fissure extends through the right upper maxillary bone Unless these fi’actures wei’e pi'oduced mortem, they must be regarded as fractures by rontrc-covp. Tilt' iK'xt case illustviites tlie great extent of fractures of tlie cranium tltat may he produced liy small [trojectiles. Tlie Army ]\Iedical Museum possesses many examples of sudi multiple comminuted gunshot fractures; hut they have been collected since the close of the War: I'ld. 110. — Shull, exliibitiiig' an extensive rmeture l>v ifrapcsliut. Spec. 1318, iSect. I, A. B'l. bI. Case. — Pj-ivalo Thomas Dikes, Co. F, 12th ]\Iissouri Cavalry, was wounded accidtaitally on October 20th, 1863, by a largo pistid ball, which shattorod and carried away a part of the fioutal and lu'arly the entire right parietal hones, and also lacerated and dashed out nearly one-third of the entire cerelnal mass, lie was immediately conveyed to the liospitaTat St. Josejdi, Missouri, lie was speechless and comatose. Death resulted in nine hours and some minutes after the recejition of the injury. Assistant Surgeon Wesley Jones, 12th Mi.ssouri Gavalry, I'ejiorts the case. It would he easy, hut of doubtful utility, to adduce other instances of oliviously fatal comminution of the cranium liy gunshot jtrojectiles. One or two more examples will suffice, and the reader may lie referred to the collections in the Army Medical Blusemn, where the subject is fully illustrated.^ -, Co. D, 17th Massachusetts Volunteers, was wounded near New Benie, Noilh C.arolina, Case.— Piivate Joseph B- geptember 1st,, 18fi2, by a fragment of shell which entered about the centre of the frontal bone, passed around the left side of the lu'ad, and emerged near the temporo-frontal suture, lie was admitted to the Douglas llosjiital, Washington, on September 5th, 1862, being partially conscious, with the right eye closed and greatly swojlen. The skull between the two aperture's felt soft. On September 10th, en abscess over the right eye (qiened about the middle of the upper lid, and pus and a few fragments of home were freely elischarged.. On S(*j)tember 13th, the' patient became comatose, and died on Septendeer 16th, 1862. At the autopsy, a large abscess was limnd in the anterior lobe of the left hemi- sphere. The ])athological s])ecimens are Nos. 236 and 514. Thefornnr shows a section of the craiuum with an extensive comnunuted fracture of the frontal hone a little to the left of the median line; the latter a wet preparation of the enc(>phalon, with perforation of the dura mater, and abscess in the u)iper i)ai t of the anterior lobe of the left half of the cerebrum. The specimens were contributed by Assistant Surgeons W. Webster and J. W. Williams, U. S. A., res|)ectively. The calvaria is represent(‘d in the wood-cut, (Fig. 111.) It is very thin. Fl(». 111. — Fracture of the frontal bone 'by a shell fragment. Spec. 236, Sect. I, A. M. M. In the Confederate hospital records, an instance is found of a patient who survived a terrible depressed fracture oi’ the skull for a fortnight, tdthough there was the comjdica- tion of erysipelas of tlie scalp; Case. — Private J. A. Hewlett, Co. A, 1st North Carolina V(duntcer.s, on May 11th, 1863, was admitted to Howard Grove Hospital, Kichmond, Virginia. He had received, at the battle of Chancellorsville, May 3d, a shell wound of the left side of the head, shattering and depres.sing the parietal very extensively, and badly lacei-ating the seal]). The j)atient was in a state of stupor, with muttering delirium, and erysipelas had invaded the seal]). The erysipelatous inflammation extended, yet the unfortunate patient lingered until May 17th, 1863. Surgeon C. D. Rice, P. A. C. S., recoi'ded the case. See, among others, specimens 1167, 860, 1166, 1319, Sect. I, A. M. M. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 215 Removal of Fragimehts after Gunshot Fractures of the Skull.— Many instances of exfoliation and of removal of necrosed or detached fragments of the cranial bones after gunshot, injuries have been relatc'd in previous pages of this Section, in the abstracts of cases in which some other feature was more prondnent. The remainder of the cases that were reported, in whicli o})erative interference, short of perforating the skull by the tre})hine, was resorted to, will be recorded in tins Subsection. The first series of twenty-eight such cases recovered, with slight disabilities, and were returned to duty: Case. — Private Benjamin Bird, Co. F, Kitli Virginia Regiment, aged ItO years, received, on August 3()tli, 1862, a gunshot wound in the riglit temporal region, fr.acturing the hone and dejiressing the fragments. Hewa.s admitted into the Confederate hospital at Charlottesville, Virginia, and on Sejitember 6th, was operated upon, when all detached pieces of hone were removed. The wound healed in six weeks without a single unfavorable symjitom. Surgeon J. L. Cabell, P. A. (h S., reported the case.' Case. — Sergeant James Stapleton, Co. A, 82d Pennsylvania Volunteers, aged 20 years, was wounded while on special duty at Cold Harbor, Virginia, on June 5th, 1864, by a conoidal ball, which fractured and depressed the right side of the frontal bone. He was taken to the field hosjiital of the 1st division, Sixth Corps, thence convej'ed to Washington, I). C., and on the 10th, admitted into Emory Hospital, where the ball was extracted. On June 14th, he was transferred to the general hosjiital, York, Pennsylvania. He became feveiLsh and suffereil great jiain. On .Tune 22d, Surgeon Henry Palmer, U. S. V., removed a jioT-tion of the bone, leaving the dura mat(‘r exjiosed. The parts surrounding the w'ound were very much inflamed, swollen, and painful. The wound healed rapidly, and on the 13th of December, 1864, the jiatient was returned to duty. He is not a jiensioner. The case is rejiorted by Surgeon Henry I’ahner, U. S. V. Case. — Hosjiital Stewaid Bernard Blair, 169th New York Volunteers, aged 23 yeai'S, was wounded at Dutch Gap, Virginia. August 13th, 1864, by a gunshot missile, which fractured the cranium a little to the right of the vertex. He was admitted to the hosjiital of the Tenth Corps, .and on the 15th, conveyed to Fort Monroe, Virginia. He was furloughed on the 4th of September, 1864. White on leave, a jiortion of the outer table of the skull was removed by Acting Assistant Surgeon C. L. Hubbell. On the 2()th of October, he entered the general hosjiital at Troy, New York. 'The wound healed rajiidly, and on the 20th of December, 1864, the patient was returned to duty. Case. — Corporal William G. Cunningham, Co. A, 44th New York Volunteers, aged 21 years, was wounded at the battle of Gettysburg, Penu.sylvania, .Inly 2d, 1863, by a conoidal ball, whicli struck the head just behind the left mastoid jirocess, passed upward and inward, and lodged in a depression of the skull. At the same time he received a flesh wound in the scalp and another in the left shoulder. He was admitted into Seminary Hosjiital on .July 4th, and transferred to the hosjiital at York, Pennsylvania, on the 19th. The patient stated that he became senseless, and remained so five days, and that he could not sjieak for nine days. Spiculae of bone and the ball were removed, aod cold water dressings ajijilied, after which the jiatient imjiroved rajiidly. On August 24th, the wound had filled with healthy granulations. A marked dejiression in the bone bebind the mastoid Jirocess could be felt. Appetite, assimilation, and secretion were good, but beadache recurred about three hours each afternoon. During Sejitember, he suffered from erysijielas of the face, but be recovered and was returned to duty on January Ifith, 1864. He is not a pensioner. The case is reported by Surgeon E. Swift, U. S. A. Case. — Private .James Duffy, Co. A, 116th Pennsylvaida Volunteers, aged 33 years, was wounded at the battle of Chaucellorsville, Virginia, May 3d, 1863, by a jiiece of shell, which fractured the parietal bones at the apex. Tie was, on the same day, admftted to the regimental hosjiital near F.ahnouth, Virginia; on May 8th, sent to the Mount Pleasant Hosjiital, Washington, and, on the 12th, transferred to the Satterlee Hosjiital, Philadeljihia. He recovered under simjile treatment and was returned to duty on the 24th of October, 1863. He was discharged .July 21st, 186.5, and pensiomal. Pension Examiner Thomas B. Reed, in October, 1867, reports that there is a large dejiression in the skull, .and that fifteen jileces of bone have been removed. The man is subject to fainting spells and dizziness, and cannot bear exposure to the sun. Case. — Sergeant .John Ij. Evans, Co. G, 91st Pennsj’lvania Volunteer.s, aged 33 years, was w’onnded at the battle of Spottsylvania Court-house, Virginia, Maj' 12th, 1864, by a conoidal ball, which fractured the left p.arietal bone. He was admitted to the 1st division. Fifth Corji.s, hospital, and transferred to the Carver Hosjiital, Washington, on the 14th. Sequestra were removed and simjile dressings apjilied to the wound. On the 2()th of .June, he was transferred to the McClellan Hosjiital, I’hiladeljihi.a, and returned to duty on the 12th of .July, 1864. He served with his regiment until the 14th of November, when he was admitted to the Fifth Corjis field hosjiital at City Point, sufl'ering from ejiilejisy, r(‘sulting from the wound of the head. He was again returned to his regiment, served till the 1st of T'ebruary, IHtFi; was re-admitted to hosjiital, and on the 27th, conveyed to Washington oil the hosjiital steamer State of Maine. He entered Camjibell Hosjiital the following day. On the 6th of Ajiril, be was transferred to the Mower Hosjiital, Phllailelphia, sent to 'riiruers’ Iv.ane on the Pith, thence to McClellan on the Kith of May, and returned to duty on the 7tb of .June, 1865. He was discharged .July lOth, 186.5, and jiensioned. On .January llth, 18(i7, Pension Examiner Cuniminskey rejiort(*d that the jiatient siiH’ered from slight exfoliation from the wound and dizziness. He was unable to ascend elevated jilaces or to be exjiosed to tbe lu'at nsioned. His disability is rated two-tliLrds. Case. — An unknown ('onfctlrmtc suhlh r belonging to Nichols's Eouisiana lirigade, was wounded at the battle of Chan- cellorsville, Virginia, Maj' 2d, 1863. 'I'he missile entered the frontal bone from oblicjue direction, passed inward and lodged alioiit two inches )iosterior to the wound of entrance. In entering the cavity of the cranium, the hall came in cdntact with the opposite margin of th(> orifice in the bone, and was deflected in its Course. An ounce or two of cerebrum was lost. The hall, considerably llattened, could be felt with tbe jioint of the little finger. The patient being semi-consciou.s, the opening in the c.iamium was enlarga'd by 1 ley’s saw, and the ball extracted. The case progressed favorably, the patient recovered, and was afterward i-etnnu*d to duty. Case. — Private Richard I'jdiam, Co. P>, 3Gth Visconsiu Volunteer.s, aged 42 years, was wounded at Cold Harbor, Virginia, .June 1st, 1864, by a conoidal musket ball, in the right side of the head. He was, on June 8th, admitted to the Lincoln Hospital, Washington, Avhere the injury was diagnosial as a wound of the .scalji. On June 18th, he was conveyed to Philadeljdiia, and admitted into the Summit House Hospital. The wound was then indolent. On the 24th of August, he was transferre^d to Satterlee Hospital, where, it was ascertained that the parietal bone was fractured at the articulation with the fi-ontal bone, one and a balf inebes fiom tbe median line. Sim])le dressings were ajtplied to tbe wounil. Quite a number of small spiculas of bone wiu-e removed. Thi; case ju-ogressed favorably and tbe wound healed, leaving a depression of one-half inch. He was returned to duty on I)ecend)er 10th, 1864, but still sufl'ered fi-om vertigo after much exertion. He was discharged Julj' 12th, 1865, and his claim for pension is ])ending. Case. — Private James A. .1. Williams, Co. A, 2d Kentucky Cavalry, aged 18 year-s, was wounded at Dairysville, Georgia, October 9th, 1864, by a conoidal ball, which fractured the superior border of the parietal hone. He entered Hospital No. 1, Nashville, Tennessee, on the 1st of November, comjdaining of constant j)ain in his head. On the 7th, the pulse was intermittent, very irregular, from 50 to 75 jier niinutt'; his bowels were constijiated, and there was a profuse discharge of carious jnis from the opening in the wound, also a small abscess beneath tbe dura mater. He was placed under the influence of chlorofonn, and Acting Assistant Surgeon M. L. Herr made a crucial incision two and a half inches in extent and removed the fractured portions of bone, exposing the brain substance. Cold water dressings w’ere applied and low diet ordered. The wound healed rapidly. He was transferred to the Jefferson Hospital, Jeffersonville, Indiana, on the 11th of December, and retiuTied to duty on the 7th of February, 1865. He was dischargi'd IMay 25th, 186.5, and died February 28th, 1867, of inflammatory softening of the brain. Case. — Private Andrew J. Gordon, Co. 3lst Ohio Volunteers, aged 21 years, w'as wounded at the battle of Chick- amauga, Georgia, September 20th, 1863, by a coi oidal musket ball, which fractured the parietal bone, ])rodncing a large depres- sion. Being conveyed to Nashville, Tennessee, he was admitted, on the 25th, into Hospital No. 3. Simple dressings only were required; the patient recovered rapidly ; w'as transferred to No. 15, October 7th; thence to No. 19, February 13th, 1864, and REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 219 returned to duty on March Otli, lS(j4. He was discharged Sepfeinher 19fli, 1804, and pensioned. On Noveinher ilOth, 1809, Pension Examiner .1. R. Reck reports tliat a large de])ression exists over the seat of the wound, througli whicli the ])ulsations of the meningeal arteiy could he clearly distinguished, d’he patient was suhject to cerehi itis upon the slighte.st exjcosiire. The effects of his en.otions, such as rage, joy, or fear, ])roduced attacks of insensihility. He could not endure the heat of a warm room and was unahle to perform any labor ivquiring mental or muscular effort. He rates his disability total iind permanent. Case. — Private George W. Ramsey, Co. A, 10th Connecticut Vohintc'ers, was woundcal in the engagement at Roanoke Island, North Carolina, February 8th, 1802, by a conoidal hall, which entered about one inch j)osterioi'l 3 ' to the fronto-parietal suture, and about two and a half inches above the ear on the left sidcc, and passed in an ohlicjue direction fi'om before backward. When brought to the field hospital he was insemsihle, surface cold, breathing stertoi’ous, pulse slow, about 40. iStimulants were freely given and the loose portions of hone removed by Surgcxm J. H. 'Thompson, U. 8. V. In the evening, eight hours after the reception of the injury, he was still unconscious, and there was that peculiar whitting by the month during ex])iration w hich frecjuently accompanies grave cases of compression; the eyes were fi.xed and the pupils much dilated. During the night, there was convulsive action of the left arm and leg; the right siile a])p<*ared ))aralyzed ; the left eye was suffused and proti udeil considerably. A clot of blood which partially filled the wound was I'einoved, and the patient laid upon his left side to give an opportunity for the blood to drain from the wound ; the hladtend)er 22d, several pieces of necrosed bone came away, and the discharge had become offensive. Ice dressings were discontinued, .and the patient was ordered to lay on his side. On September 26th, the wound was again carefully examined, the probe could be passed far down the frontal sinus without the least obstruction ; at the ujiper and outer side it came in contact with some hard and firm material, hut whether hone or bullet could not be ascertained. Sloughing of necrosed bone continued until March 20th, 1866, when a large piece of both tables was removed through incision. All necrosed portions of bone being removed, the wound healed rapidl}'. No ill effect remained, save a slight numbness at a jilace about two inches from the seat of injury. He was returned to duty Mai-cli 60th, 1866. 'The man is not on the pension rolls. The case is reported by Acting Assistant Surgeon Henry C. Hart. Beventeen patients with depressed gunsliot fractures of the skull, who liad been treated by the removal ot detached fragments of bone, recovered sufficiently to go to modified duty in the Veteran Reserve Corps. Eleven of tliem appear to have ultimately completely recovered. Ca.se. — Private Bradley Allen, Co. 1, 20th Connecticut Volunteers, was wounded at the battle of Gettysburg, Penn- sylvania, July 2d, 1866, by a piece of a shell, which fractured the frontal bone one inch above the right eyebrow and frontal sinus. He was admitted into Seminary Hospital at Gettysburg, on the same day, and was insensible for five days. On July 20th, he was transferred to the hospital at York, Pennsylvania. 'There was a star-shaped ffosh wound, with one of its tails extending across the outer extremity of the brow, and reaching three-fourths of an inch to the outside of the external angle of the left e 3 'e. 'There was extensive swelling and redness, but not much pain, and ecchymosis of the njiper ej'clid. A fr.agment of bone was removed, after which the patient improved gradually under a supporting treatment. On August 24th, the wound was irregularly shaped, almost an inch across, and was filled with granulations which were soft and (lahbv. 'Thei e was marked deju’ession of the forehead at that point, while the supra-orbital arch apjieared to bo broken. 'The brow was much deformed. 'The upper lid was of a dark red color, fdled with serum, and was, with much diflicultj’, lifted off the eye, which was uninjured. By the Ist of Novend)er, the discoloration of the eyelid had almost distijipeared, hut the upper lid was still afl'ected with ptosis. The wound in the integuments over the forehead had closed to a mere jioint. He was transferred to the Veteran Reserve Corps on Februar}' 15th, 1864. Case. — Private .Tosejdi N. Day, Co. II, 34th Massachu.setts Volunteers, aged 26 years, was wounded at the battle of Winchester, Virginia, September 19th, 1864, by a conoidal hall, which fractured the occipital bone, with slight depression. He 220 WOUNDS AND IN JUDIES OF THE HEAD, was, on the same day, admitted to the hospital of the 1st division of the Army of West Virginia, and thence, on the 27th, sent to the Slower Hospital at I'hiladelphia. Here, three small pieces of bone were removed. The treatment related refers more particularly to the topical dressings. On the 1st of January, 18G5, the patient was transferred to the Dale Hospital in Massa- chusetts. U)ion his recovery he was transferred to the Veteran Reserve Corps, May 2d, 18G5. lie is not a pensioner. Casj;. — Sergeant Joseph C. Fox, Co. F, 15Gth New York Volunteers, aged 30 years, was wouTided at the battle of Winchester, Virginia, September 19th, 18G4, by a conoidal ball, which fractured and depressed the left side of the frontal bone. He was admitted to the hospital of the 2d division. Nineteenth Corps, and, on the 22d, was sent to the depot field hospital. On September 2.'jth, the missile and some fragments of bone were extracted, while the patient was under the influence of chloroform. Simple dressings were applied. On October 17th, he was transferred to the Cuyler Hospital, Germantown, Pennsylvania, and on October 21st and 27th, Acting Assistant Surgeon John Ashhurst removed fragments of bone. Slight head symptoms existed at the time ; but the wound healed rapidly. On May 10th, 18G5, the man was sent to the Mower Hospital, and on May IGth, 1865, he was transferred to the Veteran Reserve Corps. He is not a pensioner. Case. — Private Jacob S. Jessup, Co. D, 18th Pennsylvania Cavalry, aged 22 years, was wounded at a skirmish at St. Mary’s Church, Virginia, June 15th, 1864,by a fragment of shell, which fractured the right parietal bone. He was admitted to the field hospital of the 3d division. Cavalry Corps, and thence sent to New York and admitted, on the 25th, into the McDoiigall Hospital. On the 23d of September, he was sent to the Haddington Hospital in Philadelphia. During the treatment of the case several siuculae ot the external table were removed. Jessup was transferred to the Veteran Reserve Corps on Mai'ch 2d, 18G5. He is not a pensioner. Surgeon .1. Hopkinson, U. S. V., r ecorded the case. Case. — Corpoi'al John B. Merritt, Co. B, 170th New York Volunteers, aged 22 years, was wounded at Petersburg, Virginia, June 16th, 1864, by a conoidal ball, which produced a compound fracture of the frontal b(me, over the supra-orbital region. On the same day, several pieces of bone wore extracted by Assistant Surgeon IT. A. DuBois, U. S. A. Uie patient was admitted to tlie hospital of the 2d division. Second Corps, and thence conveyed to the hospital at I’ortsmouth Grove, Rhode Island, on the 26th. On August 11th, he w.as admitted into Gi’ant Hospital, Willett’s Point, New York Harbor. By the 5th of December, 1864, the wound had closed, leaving a large scar over the eye. On the 25th of January, 1865, IMerritt was transferred to the Veteran Reserve Corps, and mustered out Jul^' 13, 1865. He is a pensioner. The next case refers to a man who, apparently, belonged to one of the classes of recruits who were hnown during ilie latter part of the war as “ Bounty Jumpers the class of disabled men, who, through the culpalile negligence of the local examining officers, were allowed to arfain and anain ro-enlist, and to receive the large bounties then offered, only to be discharged in a few W’eeks or to encumber the hospitals : Case. — Private George Moritz, Co. I, 7th United States Infantry, aged 34 years, was wounded at the battle of Chancel- lorsville, Virginia, May 1st, 1863, by a conoidal ball, which entered the right parietal bone, near the coronal suture, producing a stellate fracture of both tables, and lodged. The ball and portions of comminuted bone were I’emoved on the field, through a crucial incision. The patient was conveyed to W’ashington, and entered Lincoln Hospital on the 15th of June, remaining until the 11th of September, when he was returned to his regiment to be mustered out of service. On the 4th of .January, 1864, he entered the 3d Division Hospital, Alexandria, Virginia, as a recruit of the 2d New York Cavalry. On March 31st, he was transferred to Fairfax Seminary Hospital, lu-ar Alexandria, Virginia, and discharged from the service on the 5th of May, by reason of impaired intellect and derangement of the nervous .system, being unfit for the Veteran Reserve Corps. On the 5th of July, 1864, he entered Carver Hospital, Washington, as a private of Co. 1), 7th New Jersey Volunteers, suffering from cephalalgia to such an extent as to entirely disable him for duty. The wound was entirely healed. There was a depression over the right parietal protuberance about an inch in diameter, and half an inch in depth. On the 30tli of September, he was placed on light duty in the hospital, and on the 25th of April, 1865, transferred to the Veteran Reserve Corps. He is not a pensioner. Ca.se. — Private Charles Rogers, Co. G, 44th Illinois Volunteers, aged 20 j-ears, was wounded at tlu! battle of Chick- amauga, Georgia, September 20th, 1863, by a round ball, which fractured the right parietal bone, a second ball lodged beneath the lachrymal sac, and a third struck near the centre of the left orbit at the lower margin. He was admitted into hospital at Stevenson, Alabama, on the 25th ; transferred to Hospital No. 8, Nashville, Tennessee, October 28th ; sent to Hospital No. 3, Imuisville, Kentucky, November 29th, and, on the following day, again transferred to the hospital at Quincy, Illinois. A portion of both tables of the skull had been removed previous to his admission to the latter- hospital. Simple dressings and full diet were ordered. He recovered and was trausferr(‘d to the Veteran Reserve Coi'ps on the 23d of March, 1864. He is not a pensioner. Acting Assistant Surgeon F. K. Baily repoi-ts the case. Ca.se. — Sergeant John Reagan, Co. I. 37th Wisconsin Volunteers, aged .30 years, was wounded near Petersburg, Virginia, •Tune 18th, 1864, by a coiroid.al ball, which lacei-ated the scalp, and slightly fractured the left parietal bone irear the jirnction of the coronal and sagittal sutures. He also received a gunshot wound of the leg. He was admitted to the hospital of the 3d division. Ninth Corps, sent to City Point, Virginia, and thence conveyed per Hospital Steamer Connecticut to Annapolis, Mary- land, entering 1st Division Hospital on June 20th. On the 17th of August, he was transferred to the hospital at York, Penn- sylvania, where, on the following day, a small piece of bone was removed. 'Ihe wound was dressed with cold water, dud in about two w'eeks was entirely healed. Spasms occurring, the wound was reopened with a view to discover the cause, but nothing unusual could be observed. The patient was furloughed on the 23d of September, 1864, re admitted on October 17th, and remained until the 13th of March, 1865, when he was transferred to the Veteran Reserve Corps. [He was sent to the Sol- diers’ Home, at Dayton, Ohio, and committed suicide, May 21, 1873, by taking arsenic.] EEMOVAL OF FEAGMEKTS AFTEE GUNSHOT FEACTUEES OF THE SKULL. 221 Case. — Corporal J. Y. Sclianjlhie, Co. 1, 51st IVmisylvania Volunteers, was wounded at the battle of I’rederieksburg, Virginia, December IStli, 1862, by a piece of shell, which fractured and depressed the frontal bone to the left of the median line, near the coronal suture. He fell senseless, but consciousness soon returned, when he was conveyed from the lield. Ho was taken to Washington, and entered the Judiciary Square Ilosjiital on the l^tli, where coma supervened. During the evening of the same day, several fragments of bone were removed and the depressed jiortions elevated. No anesthetic was used. The patienf rallied and became partially sensible; strabismus disa]ipcared before morning. On the second day after the operation, his pulse was 76, appetite fair, but the mind rather slow. On the 1st of January, 186J, he was a little giddy and complained of slight headache, but was otherwise impioving rapidly, lie was transferred to the Invalid Corps on May ITth, 186J. He is not a pensioner. Case. — Erivate Eeuben Lysle, Co. 1, 14Sth Pennsylvania Volunteers, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a piece of shell, which fractured and d('j>ressed both tables of the cranium. Surgeon C. S. Wood, (>6th New York, laid open the scalp, cxti acted the loose portions of the bone, and elevated the de])ressed parts. The brain, apparently, was not injured. ' For scveial weeks he was treated in the 1st division. Second Corps, held hospital, and on June 14th, admitted into Carver Hospital, Washington. On the ICth, he was transferred to West’s Building Hospital, Baltimore, and thence, on July 4th, to the general hospital, Point Lookout, Maryland. He recovered and was transferred to the Veteran Reserve Corps, June 28th, 1804. The case is reported by the operator. Surgeon C. S. Wood, C6th New YTrk. The i)atient’s naine does not appear upon the Pension List. Case. — Private Albert Sobers, Co. B, 1st Mhiuesota Volunteers, aged 20 years, was wounded at the battle of Gettysburg, Pennsylvania, July 2d, 1803, by a fragment of shell, which ti-actured the light parietal bone near the vertex. He was also struck in the left leg by a conoidal ball, which entered at the middle third upon the front surface, between the tibia and hbula, and passed directly upward, injuring the head of the fibula, whence it was cut out by a free incision at the outer side of the knee. He was admitted to the Seminary Hospital, Gettysburg. The leg began to swell and considerable pus formed in front of the semi-membranosus along the outside of the thigh. On July 6th, the ims was evacuated, and a gradual improvement took jilace. On July 18th, he was sent to the hospital at York, Pennsylvania. ’A small piece of boue was removed from the cranium, and from the aperture left, at different times, small portions of brain exuded. For a few days, the patient suffered from dizziness ; but the wound healed kindly, and, in December, 1863, it was covered with scalp and hair. The wound of the leg had also healed; but the leg was somewhat "weak and could not be straightened. He was transfei'red to the Veteran Reserve Corps on December 24th, 1863. He is not a pensioner. The case is reported by Acting Assistant Surgeon H. F. Bowen. In five of the cases of the foregoing series the fractures were produced. by shell fragments, and in six, by musket balls. The names of six of the patients who had undergone operations for the removal of detached fragments of bone after depressed gunshot fractures of the skull, are found on the Pension Poll. Three of these pensioners suffered from epileptiform convulsions, two from dizziness and impaired vision, and one from headache and nervousness : Case. — Private Sebastian Langendorf, Co. H, 14th Ohio Volunteers, aged 37 years, was wounded at Atlanta, Georgia, August Cth, 1864, by a conoidal ball, which fractured the left side of the frontal bone, just anterior to the coronal suture. He was at once admitted to the hospital of the 3d division. Fourteenth Corps, thence was conveyed to Nashville, Tennessee, where he entered Hospital No. 1, on the 17th. The brain substance was exposed to view. On the 6th of October, a circular piece of bone, over an inch in diameter, was removed. Simple dressings were applied. On the 25th of November, the patient was transferred to Evansville, Indiana, where he i-emained until the Kith of January, 1865, when he was sent to Camj) Dennison, Ohio. He was linally ti’ansferred to the 1st Battalion, Veteran Reserve Corps, on March 31st, 1865. A. M. M. Phot. Series, Vh)l. 1, page 6. This soldier was discharged the service August 5th, 1865, and pensioned, because of epilepsy. On November 12tli, 1867, I’ension Examiner Samuel S. Thorn rates his disability total and temporary. Case. — Sergeant L. E. Claik, Co. E, 26th Michigan Volunteers, aged 21 years, was wounded near Petersbuig, Virginia, June 17th, 1864, by a conoidal ball, which fractured the right temporal bone two inches above the ear, and lodged. He was conveyed to the hospital of the 1st division. Second Corps, and remained insensible until the next day, when the ball was exti'acted and sev’eral fragments of boue were removed. The operation gave great relief; but the left arm and leg remained paralyzed until the middle of July, when the patient recovered the use of the leg, and jiartial use of the arm. For two or three days after the removal of the ball he was almost totally blind; but, in December, his vision was only slightly im])aired. He was, on December 9th, sent to Augur Hospital, Alexandria; on December 16th, to Armory Square, Washington, and on I'ebruary 20th, 1865, to Cliffburne Barracks, whence he was transferred to the Veteran Reserve Corps on M.arcli 25th, 1865. Heyvas discharged the service June 28th, 1865, and pensioned. In June, 1866, Pension Examiner R. C. Hutton reported th.at the man needs constant watching on account of lo.ss of intellect, and of frequejitly recurring spasms, caused by compression of the brain. C.V.SE. — Private Alfred Green, Co. H, 70th I’ennsylvania Volunteers, aged 22 years, was wounded at Fort Wagm'r, S(juth Carolina, July llth, 1863, by a conoidal musket ball, which fractured the ti-ont.al bone, right side. Ho Vvas taken i)i isoner and remained in the hands of the enemy until September 30lh, when he was admitted to the 2d Division Hospital at Annapolis, Maryland. In October, he was transferred to I’hiladelphia, where he arrived at the Satterlce Ilosjiital on the 25th. Several small spicuhe of bone had been removed from time to time, but the wound was nearly healed, leaving a deep scar. On January 25th, 1864, he was transferred to the Veteran Reserve Corps, and was discharged Octolxu' 28th, 1864. In February, 1870, Pension E.xaininer A. Davis reported that the man is subject to tie(pient and severe convulsions of an epileptic character, which occur on an average once a week, and last from one-half to six hours. 222 WOXTNDS and injuries of the head, Cask. — Private \V. Kidder, Co. A, iJd Massacliiisetts Volunteers, aged ‘23 years, was wounded at the battle of Gettsybnrg, Pennsylvaniti, July 2d, 1803, by a eonoidal ball, wliicli fractured both tables of tbe skull without causing depression. He ir inained in tbe Held liospilal until the 18tb, when lie was transferred to tlie hospital at York, Pennsylvania, He so far recovered ii’oni tbe injury that be was transferred to the 1st battalion. Veteran Reserve Corps on the 24tb of December, 1803. He was discharged July 25tli, 1804. In January, 1808, Pension Examiner Nathan Allen reported that this man siifi'ers from dizziness and loss of sight upon stooping or excitement. Cask. — Private Elkanah B. Vondei’smith, Co. H, 88 th Illinois Volunteers, aged 39 j’ears, was wounded at Dallas, Georgia, JMay 29th, 1804, by a eonoidal ball, which fractuieil the outer table of the cranium at the apex and lacerated the scalp exten- sively. He was, on the following day, admitted into the field hospital of the 2d division. Fourth Corps, whence he was trans- ferred to Ack worth, Georgia, on the 8 th of June. Dn the 17th, he entered the genei al field hospital "at Chattanooga, Tenne.ssee ; was transferred on the ‘29th, to Eouisville, Kentucky, entering Totten Hosjiital on the 30th; on July 5th, sent to Jefferson Barracks Hosjiital, Jlissouri, and on the ‘27th, transferred to Quincy, Illinois. A small jiiece of the outer table of the skull was removed on the 4th of August, fsinijile dressings were ajijdied, and full diet was ordered. The wound healed rajiidlv; and by the 1st of January, 18C5, it had entirely closed. The jiatient’s general health was excellent; but he could not endure much fatigue, lie was transferred to the 2d battalion of the Veteran Reserve Corjis oii the 13th of Eebriiary, 1805, and discharged from the service July 15th, 1805, and jiensioned. Pension Examiner A. E. Hand, under date of August 28th, 1805, rejiorts that the man is unable to do anything by reason of dizziness and blindness on stooping. Cask. — Private A. J. AVilliainson, Co. C, 19th Indiana Volunteers, aged 25 year.s, received, at the battle of Gettysburg, Pennsylvania, July 1st, 1803, a gunshot injury of the cranium. The missile entered at the vertex and made an ojiening about three inches in length. The bone, ajipareutly, was not injured. He was admitted to the hosjiital of the 1st division. First Corps, and on July 7th, sent to Mower Hosjiital, Philadeljihia. On July 8 th, the wound had almost healed ; the granulations, being somewhat jirofuse, were touched with nitrate of silver. Dn August "27th, the jiatieiit comjilaiued of jiaiii in the chest, and a blister was ajijilied, giving relief. ( )u August ‘lOtli the wound ha'd become jiainful and discharged more freely than usual, and on August 31st, a Jiiece of the outer table of the skull, almost the size of a thumb nail, was removed. The wound then healed, but the man comjilained of vei tigo. He was transferred to the 2d battalion Veteran Re.serve Corjis, and on December 19tli, 18(i3, sent to liidianajiolis, Indiana. He was discharged Ajiril (ith, 18(J4, and jiensioned. He sullers from constant headache and nervousness, and his disability is rated total. Til the yixteeii following cases, in which fragments of hone were removed after gun- shot fractures of the skull, the patients recovered and were returned to duty at intervals at Irom one to twenty months, the average jieriod of treatment in hospital being seven and oiie-half months. All but two of the [)atients were under thirty years of age, and a majority between seventeen and twenty-five years of age. In all of the cases, the frac- tures were on the upper and anterior, or else on the superior lateral portions of the cranium : Ai-GKI!, Joskpii E., Plivilte, Co. B, 35th Iiiwa, aged 17 years. I’leasaiit Hill, Ajiril 9th, 18G4. Fracture at vertex by colloidal musket ball. Gaj'oso Hosjiital, Memjibis. Two fragments of bone removed. Duty, June 2d, 1804. An1)K1!S(I2s', Samukl, Private, Co. E, 11th Pennsylvania, aged 18 years. Wilderness, IMay (ith, 1804. Frontal fractured by colloidal hall. Mount Pleasant Hosjiital, Washington. In May, fragments of both tables removed. Duty, August 20th, 1804. Eki.miws, Saimukk, Private, (hi. A, 27th Indiana, aged 2‘2 years. Gettysburg, .July 3d, 1803. Fracture of right jiarietal by colloidal ball. Mower Hosjiital. August 0th and 9lh, necrosed bone removed. Duty, May 3d, 1804. Eostki:, Cai.kI! R., Private, Co. B, 102d Pennsylvania, aged 17 years. Wilderness, May 5th, 1804. Fracture at vertex by eonoidal ball. I’inley and Satterlee Hosjiitals. Fragments of external table removed June 17tli. Duty, lUarch 17th, 1805. HalloCK, Hknkv 8 ., Pi'ivate, Co. F, 24th Iowa. Port Gibson, May 1st, 1803. Gunshot fraetiire of left jiarietal. Union Hosjiital, IMenijiliis. Removal of fragments, July 1st. Duty, August 30th, 1803. FArottTJO, Zkkiiamaii, Private, Co. F, ‘23d Ohio, aged ‘27 years. Autietam, iSejitember 17th, 1802. Fracture of frontal by eonoidal ball. Frederick and Baltimore hosjiitals. Removal of fragments. Retained in hosjiital as nurse. Duty, May 10th, 1804. McC.vnn, R., Quartermaster Sergeant, 1st Louisiana Union Volunteers. Port Hudson, June 14th, 1803. Gunshot fracture of left jiarietal. Regimental hosjiital. January 12tli, 1805, removal of large jiiece of jiarietal bone tbrough crucial incision. Duty, I'ebruary 3d, 1805. Pkklks, Jaimks W., Private, Co. G, 150th New Yoik, aged ‘25 3 'ears. Winchester, Sejitember 19th, 1804. Gunshot fracture of jiarietal bone by eonoidal ball. Samp’ Hook and York hosjiitals. Fragments of inner table removed, October 5th, 18(i4. Duty, December 14th, 1804. RoiKii, Lkvi, Private, Co. A, 143d Pentusylvania, aged 19 j-ears. Petersburg, June 17th, 1804. Fracture of cranium at vertex by eonoidal musket ball. New York and Philadeljihia hosjiitals. Several fragments of bone leinoved. Duty, February 15th, 1805. EEMOVAL OF FRAGINIENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 223 Rooney, Mahtin, Corpoml, Co. A, 119th New York, aged 23 years. Lost Mountain, June 15th, 18(14. Fracture of teiiiporal bone by conoidal innsket ball. Chattanooga, Nashville, and New Y’ork hospitals. August 12th and 21th, Ibnr large fragments of bone removed by incision. Ihity, November 21st, 1804. SK.vitS, 1>A\1I) T., Private, Co. C, llOth ( )hio, aged 35 years. 'Winchester, September 19(h, 1804. Gunshot fracture of cranium. Field and Frederick hospitals. Fragments of loose bone removed, lluty, November 23d, 1804. Shinn, FliANKLlN, Private, Co. 11, 23d New Jersey, aged 21 yeaivs. Fredericksburg, December 13th, 1802. Fracture of parietal bone by shell, llarewood and Satterlee Hospitals. A thin shell of bone removed, February 13th, 1803. Duty, •hme 2d, 1803. Styles. Geoi!GE M., Sergeant, Co. K, 98th Peim.sylvania. aged 29 years. Gettysburg, July 2d, 1803. Slight fracture of left i)arietal bong by conoidal musket ball, llaltimore, Annapolis, and Philadel[)hia hospitals. Removal of necrosed bone thi-ougb ci'ueial incision and by an elevatoi’, January 18th, 1804. Duty, March lUth, 1804. AV1LLIA.M.S, TTiosias, Corpoial, Co. E, 102d New York Volunteers, aged 32 years. Cane River, Louisiana, Ajuil 23d, 1804. Gunshot fracture of right ])arietal. Ilaton Rouge Hospital. Fragment of external table removed May 30th, 1804. Duty, August 27th, 1804. WOGI), TTioma.S L., I’rivate, Co. G, 2d New York Heavy Artillery, aged 18 years. Petersburg, June 10th, 1804. Frac- ture of left parietal by conoidal musket ball. City I’oint and New York Hospitals. Fragments of bone and ball removed. Duty, March 2d, 1805. YocUJI, Heniiy, I’rivate, Co. C, 150th I’ennsylvania, aged 24 years. Gettysburg, July 2d, 1803. Gunshot fracture of frontal bone by conoidal musket ball. llarewood and Satterlee Hospitals. Fragments of bone from both tables removed. Duty, January 25th, 1804. In tlie following eleven cases, lielonging to the class under consideration, the patients were sent to inodihed duty in hos})ital or garrison ; hut their physical disabilities ultiinatol}" compelled their dischtirge and admission to the I’ension List. Nearly all were young soldiers, the ages ranging from seventeen to twenty-seven years. The fractures were of the upper fronttd, tenpioral, or parietal regions, except in the instance of one fracture of the occi})ital. The fractures were produced by conoidal halls in nine, and by shell i'ragments in two, of this scries of cases. The average duration of hospital treatment was aljoiit six months : Dowty, Aisneii S., I’rivute, Co. R, 33d Massachusetts, aged 20 years. Rusaca, May 15th, 1864. Fracture of left parietal by conoidal hall. Nashville and Louisville hos))itals. Duty, September 9th, 1864. Discharged June 11th, 1865. E.xaminer Foster Hooper, M. D., reports. May 21st, 1869, that a number of pieces of bone have been removed, leaving a large cicatrl.x, much depressed, and that the man is subject to fits anil headache. Doyle, James, Private, Co. M, 24th New York Cavalry, aged 23 years. Cold Harbor, Virginia, June Ist, 1864. Fracture of left parietal bone by conoidal musket ball. Washington and Philadelphia hospitals. Duty, February 7th, 1865. Mustered out July 23d, 1865. E.xaminer 11. W. Loomis, M. D., January 20th, 1866, states that several pieces of bone have been removed. The right ami is ]iartially, and the right leg slightly, paralyzed. The vision of both eyes is imfiaired and he suffers from dizziness and pain. Gillem, Eow.vud, Captain, Co. G, 1.58th New York, aged 26 years. Hatcher's Run, Virginia, March 29th, 1865. Fracture at verte-x by conoidal b.all. Point of Rocks and Fort Monroe hospitals. Duty, June 30th, 1865 ; discharged. Examiner .lames XT-ill, M. D., rejiorts, August 2(1, 186.5, that a fragment of bone has been removed and that the pensioner is subject to hemiplegia and nervous irritability. Golden, P.vtjmck, Private, Co. D, 2d New Y'^ork Heavy Artillery, aged 27 years. North Anna River, May 18th, 1864. Fracture of frontid bone, with e.xtensive laceration by conoidal ball. AVashington and Philadelphia hospitals. June 19lh and 25th, removal of fragments of bone and ball. Duty, Sei)tember 22d, 1864 ; dischaiged. Examiner 11.15. Day, JM. D., states that the sight of the left eye is impfu feet. In September, 1869, the pensioner filed an application for an increase of pension. II.VNCOCK, John F., I’rivate, Co. F, 25th Ohio, Chancellorsville, May 3d, 1863. Fracture of parii-tal bone by c(moidal ball. Washington, Philadelphia, and Covington liospitals. Duty, December 1st, 1863; discharged July 26th, 1864. Examiner Julius Nichols, M. D., rejrorts that pieces of bone have been removed, that the hearing is imperfect, and that the pensioner is subject to dizziness. Hays, .James, Cor|)oral, Co. D, 87th New Y'ork, aged 23 years. Fair Oaks, Ma_v31st, 1862. Fracture of temi)oral bone by conoidal ball. R’ew York hospitals. Ten pieci-s of bone removed at different ixn-iods. 1 )uty, February 26tb, 1863 ; discharged March 27th, 1863. Examiner D. R. Good, M. 1)., reports, Alarch 21st, 1864, that e.xfoliation is still going on, and that the man is suffering from incipient jdithisis. .Johnson, William .1., Private, Co. A, 2d New York Mounted Rilles, aged 17 years. I’etersburg, June 25th, 1864. Fracture of cranium, right side, by conoidal musket ball. Washington and Philadel[)hia hosi)itals. Removal of large fragment of bone. Duty, .January 18th, 1865 ; discharged August 10th, 1865. Examiner J. II. Uelmer, M. D., January 10th, 1867, states that the pen.sioner is suffering from phthisis pulmoualis, and that his disability is total. 224 WOUNDS AND INJURIES OF THE HEAD, Sticknky, Wuxiam 11., Private, Co. B, Clli New Hampshire, aged 24 years. Petersburg, July 6th, 1864. Fracture of parietal bone at vertex by couoidal ball. City Point and Philadelphia ho.spitals. Removal of fragments of bone. Duty, October 17th, 1864 ; mustered out November 27th, 1864. Examiner I’hiiicas Spalding, M. D., May 15th, 1866, states that the ])ensioner is afflicted with numbness and loss of action in aim, that he suffers almost constant [lain in the head, and that his stomach is very irritable. SxuiiDEVANT, Clakk, Private, Co. E, 27th New York. Chancellorsville, May 3d, 1863. Fracture of cranium by shell. Treated in Washington hospitals. Removal of loose fragments of bone. Duty, August 11th, 1863; discharged May 31st, 1864. Examiner J. L. Stewart, M. D., states that exercise gives evidences of pressure on the brain. McCain, William, Private, Co. I), 63(f Pennsylvania. Gettysburg, July 2d, 1863. Fracture of cranium; portion of bone carried away by conoidal ball. Gettysburg, Harrisburg, and Y'ork hospitals. Duty, July 13th, 1864 ; discharged. Exam- iner A. B. Otto, M. D., reports, August 21st, 1865, that numerous pieces of bone have been removed; that the sight of the right eye is almost entirely destroyed, and the left sympathetically affected. Smith, Williaim P., I’rivate, Co. B, IHli Vermont, aged 23 years. Newport Bairacks, February 2d, 1864. Fracture of occipital bone. Morehead City and Burlington hospital.«. March 26th, removal of piece of bone. Duty, Augu.st 1st, 1864; discharged. Examiner C'yrus Porter, M. D., September 16lh, 1869, states that there is partial de-afness, attended with dizziness and headache. Nearly all of these patients suffered from vertigo, headache, or some disorder of the cerebral fimctions ; one had epileptiform convulsions ; three suflfered from paralysis of some of the motor nerves; two were deaf; three had defective vision, and two were laboring under pulmonary phthisis at the date of the last report of the pension examiner. Discharged and Pensioned .- — Of the numerous cases reported of patients who recovered after fragments of bone, fractured by gunshot projectiles, had been removed, those cases in which the names of the patients remain on the Pension Roll will first be considered ; Case. — Private William Angus, Co. E, 173d New York Volunteers, aged 42 years, was wounded at Port Hudson, Louisiana, June 14th, 1863, by a conoidal ball, which comminuted and depressed the right parietal bone. He was conveyed to New Orleans, and entered University Hospital on June 17th. Assistant Surgeon P. S. Conner, U. S. A., removed nine frag- ments of bone from the wound. The fracture was situated immediately superior and anterior to the right parietal emi- nence, and was an inch and a half by three-fourths of an inch in extent, tlie dura mater being uninjured. The left side of the body became paralyzed. However, this disappeared a few days after the operation, and the patient so far recovered that he was placed on duty in the hospital as a nurse. On June 1st, 1864, he was transferred to the Clentral Park Hospital, New York, and on June 16th, 1864, he was discharged fi’om the service. The wound of the scalp was then pei-fectly healed, with an hiatus in the bony covering of the brain one and one-fourth by three-fourths of an inch in extent, closed, apparently, by a tough membranous septum. The fragments removed are outlined in the adjacent wood-cut, (Flli. 112.) This patient was reported, in 1871, as pensioned because of mental imbecility and general debility. Case. — Captain Winfield S. Barr, Co. B, 105th Pennsylvania Volunteers, aged 23 years, was wounded in an engage- ment before Petersburg, Virginia, August 16th, 1864, by a conoidal ball, which fractured the mastoid process of the temporal bone, and injured the base of the occiiiital. He was admitted to the hospital of the 3d division. Second Corps, and thence was sent to the Satterlee Hospital. On admission, August 20th, the patient was delirious, and the wound had an unhealthy aspect. On August 23d, haemorrhage to the amount of eight ounces occurred from the posterior auricular and some of the small deep cervical branches. This bleeding was arrested by styptics, compress, and roller. On the following day luemoi'rhage recurred, and about five ounces of blood was lost. From that time the case progressed favorably. On December 7th, several spiculae of neci-osed bone came away, and, on December 30th, a large portion of the mastoid process was removed. On January 19th, 1865, Captain Barr was transfeiTcd to the Officers’ Hospital, Philadelphia, and thence mustered out of the service. On Jlay 15th, 1865, he was a pensioner, and his disability was rated as total and permanent. Case. — Private Freeman Behymer, Co. A, 104th Ohio Volunteers, aged 37 years, was wounded at the battle of Franklin, Tennessee, November 29th, 1864, by a conoidal ball, w'hich fractured the parietal and frontal bones at the junction of the sagittal and coronal sutures'. He was admitted on the following day to hospital No. 8, Nashville, where he remained until December 9th, when he was transferred to the Joe Holt Hospital, Jeffei’sonville, Indiana. On December 20th, he was sent to the Camp REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 225 Dennison Hosi)ital, Ohio. On May (ith, 18o5, the parts had heconie infianied, painful, and suppurating. Tlie patient was chloroformed, when Surgeon Clark McDermont, U. S. V., made a slight incision through the integument, and removed a loose, irregular-shaped piece of dead bone two and a quarter inches long and two inches wide. Glycerine dressings were applied. The case progressed favorably, granulations being abundant and healthy, and on October 31st, 1835, the man was discharged from the service. A communication from the Commissioner of Pensions, dated July, 1808, states that Behymer is a pensioner, and that his disability is rated total and permanent. Case. — Private Emanuel Brown, Co. I, 4th Rhode Island Volunteers, was wounded in an engagement near Petersburg, Virginia, July 30th, 1831, by a conoidal ball, which fractured the cranium. He was admitted into the field hospital of the 2d division. Ninth Army Corps, where fragments of bone were removed, and on August 5th he was transferred to Knight Hospital, New Haven, Connecticut, whence he was discharged from the service on October 2Gth, 1864, by reason of expiration of term of > service. There is a water color drawing of the recent wound in the Army Medical Museum. In March, 1868, Brown was a pensioner, his disability being rated total and permanent. Pension Examiner Henry Wheaton Rivers, formerly Surgeon 4th Rhode Island Volunteers, reported that there was an opening, closed by fibrous tissue, between the bones of the frontal and pari- etal regions, of an inch in w'idth and about two inches in length. “He has pain, dizziness, defective vision, and deafness in left ear. The present disability is total and permanent. The disability is not caused by any fault of his own.” Case. — Second Lieutenant Isaac Branson, Co. E, 19th Indiana Volunteers, aged 28 years, was wounded at the battle of South Mountain, September 14th, 1802, by a round musket ball, which entered the mastoid portion of the left temporal bone about one and a half inches above and behind the meatus auditorius externus, and lodged. After remaining insensible for a few minutes, he attempted to rise, but being unable to control his limbs, he would constantly stumble and fall. He states that he introduced his little finger into the wound for more than an inch, and could feel the brain substance. Spiculm of bone were removed. On September loth, he was sent to the hospital at Frederick, and thence was transferred, on September 19th, to the Patent Otfice Hospital at Washington. The wound being very painful, he did not wish to have it probed, and therefore did not tell the attending surgeon that the ball remained in the wound. Simple dressings were applied. For several weeks he stag- gered and had fever, but never was delirious. Spiculm of bone continued to come away for some tveeks, but the wound healed gradually, and on October 3d the patient was sent to New York. He was afterward returned to his regiment, and mustered out on October 23th, 1834. He was e.xamined on March 29th, 1833, by Dr. G. W. II. Kemper. A prominent scar marks the entrance of the ball, which, according to the patient's belief, remains in the cranium. He is subject to headache in the back part of the head. His intellect does not seem to be impaired. On October 7th, 1837, Pension Examiner J. C. Helm reports the patient as nearly unfit for any business, owing to vertigo, headache, and dizziness. Pie rates his disability as total and permanent. Case. — Private Reuben Clark, Co. II, 31st Maine Volunteers, aged 21 years, was wounded at the battle of Petersburg, Virginia, April 2d, 1835, by a fiagment of shell, which struck near the anterior superior angle of the right parietal bone, pro- ducing a fissure one and one-half inches in length, denuding the bone of the periosteum, and slightly depressing the external table. He was admitted into the general field hospital of the Ninth Army Corps on the same day, and a few days later sent to Washington, and admitted on the 5th into the Carver Hospital. On the 8th, the patient was transferred to the Mower Hospital at Philadelphia. -Simple dressings were used. On the 13th, prominent cerebral symptoms, with pain in the head and high fever, were ushered in by a chill. Cathartics were administered, and cold water a))plied to the head. Small doses of calomel and opium were given for a few days afterward. Some small pieces of necrosed bone were subsequently removed. On June 15th, 1835, he was discharged the service. The case is reported by Acting Assistant Surgeon W. P. Moon. In August, 1836, Pension Examiner James C. Weston reports that this pensioner is sometimes subject to dizziness, especially on stooping, and that his eyes fill with tears when reading. His disability is rated one-half. Case. — Private Edward W. Hawkins, Co. E, 28th U. S. Colored Troops, was wounded near the Chickahominy, Vir- ginia, June 25th, 1834, by a conoidal ball, which apparently injured the scalp only. He was admitted on June 28th to L’Ouver- ture Hospital, Ale.xandria, and returned to duty July 18, 1884. On August 17th, he was admitted to Satterlee Hospital, where the case was diagnosticated a fracture of the cranium. The records also state that the patient’s skull had been operated upon, at the time of injury, by the removal of detached fragments. He was suffering from chronic diarrhoea, which gradually amended under treatment. On September 29th, he was sent to Summit House Hospital; on March 29th to Beverly; and on May 12th to Whitehall, where he was discharged the service May 2Gth, 1865. On September 26th, 1868, Pension Examiner W. D. Thomas states that the patient complained of inability to labor because of vertigo and intense pain in the head. He rated his disability at one-half and temporary. Case. — Lieutenant A. G. Williams, Co. E, 63d Pennsylvania Volunteers, received, at the battle of the Wilderness, Vir- ginia, May 5th, 1834, a gunshot fracture, with depression of the frontal bone, left side; also a wound of the temple; the occipito- frontalis muscle was severed. He was admitted to the hospital of the 2d division. Sixth Corps, where the depressed portions of bone were removed; thence he was conveyed to Washington, D. C., and there attended in his quarters until May 18th, when he was furloughed. He reported at the Otlicers’ Hospital at Annapolis, Maryland, on July 27th, and on August 9th was discharged from the service by re.ason of Special Order No. 261, A. G. O., August 6th, 1884. He subsequently made application for a pen- sion, and was examined by G. McCook, examining surgeon for pensions, Pittsburgh, Pennsylvania, who reported that the third pair of nerves were affected. His disability is rated at one-fourth and permanent. Case. — Private Walter Wheeler, Co. B, 91st New York Volunteers, aged 37 years, was wounded before Petersburg, Vir- ginia, April Isf., 1835, by a conoidal ball, which entered above the anterior zygomatic articulation, fractured and depressed the temporal bone, and emerged just above the external meatus, right side. He was conveyed to the depot field hospital of the Fifth Army Corps, where he remained until the 18th, when he was sent to Washington, and admitted into the Harewood Hospital on the 19th. Three days later he had a slight hemorrhage from the common temporal artery, which was ligated. The wounds of 29 226 WOUNDS AND INJURIES OF THE HEAD entrance and of exit 'were eonnnunicated, wlien it was found tliat a small |>ortiou of bone at tlie point of exit was denuded of pericra- nium. Snbsecjuently the ibmuded ])ortio7i was removed. By June I7tb Wheeler bad fully recovered, and on June ‘JOtb, 1S65, was discharged from tlie service. In July, 1838, be was a pensioner, bis disability being rated as total and permanent. Pboto- graplis of the case will be found in Vduine VII, I’bot. Series A. M. 1\I. C.\SE. — Corporal Ezra Scarborough, Co. G, loth New' .lersey Volunteers, aged 84 years, was wounded at the battle of Cbancellorsville, Vii'ginia, Jlay 3d, 18C3, by a musket ball, 'wliicb fractured and depressed a portion of both tables of the right parietal bone near the vertex. He was sent to a field hospital ; thence to Washington, and was admitted into Stanton Hospital, May 8th. The left ui)per and lower exti’cnnties wei'e paralyzed, except the fingers of the left hand, which could be slightly flexed. The paralysis was limited to the motor nerves, those of sensation being unaffected. He complained of headache, and there w'as some confusion of intellect, though no delirium. The j)upils were contracted and .symmetrical, but sluggish to stimulus of light. The skin was soft, moist, and natui'al in temperature. Water dressings and ice were aiiplied to the wound, a saline purgative w'as administei’ed, and low diet was ordered. The case progressed favor.ably, and on the 10th, the patient could flex the left elbow. The pupils were still contracted and sluggish, the pulse ranging from G.5 to 70. By the 25th, the patient had recovered control of the left arm, though it was not yet as strong as the right; the pu])ils were still sluggish, but not con- tracted; the detached bone appeared elevated. On .Tune 7th, a detached fragment of the inner table, one inch in length and h.alf an inch in width, was removed by Surgeon John A. Lidell, U. S. V. It consisted of diploe and the vitreous table, and when I’emoved, the dura mater and the i)ulsations of the brain were distinctly visible. Tbo ])upils had become natural in size, contracting readily under the stimulus of light; the wound suppurated freely and looked healthy, having slightly contracted. The applications of ice were now discontinued. On the 12th, the pulse had risen from 65 to 80 ; paralysis of left leg had diminished in a marked degree. June 24th, pai’alysis was still diminishing, but the patient still complained of headache induced by constipa- tion. .Tuly 8th, the brain pulsations were no longer visible, the patient was able to leave his bed, and on August 1st, could walk with the aid of a cane. He continued to improve rapidly, and on the 17th, had recovered sufficiently to' go home on fuilough. He was transferred to Ward Hospital, Newark, New Jersey, on November 13th, 1863, and was discharged the service on Decem- ber 11th, 1863, and pensioned. On June 6th, 1853, Pension Examiner E. Swift reports that a deep depression existed over the ci’iginal seat of in jury. There wars pai’alysis of the left side, mon? marked in the leg than in the arm. The limbs were atrophied and weak, although they preserved their natural movements. The patient suffered a great deal from headache and from severe pain in the affected limbs. His speech was much impaired, and he was unable to do manual labor. His disability was then rated total and perm.anent. A communication from the Commissioner of Pensions, dated January 3d, 1868, states that Scarbor- ough was a pensioner, his disability being rated total and temporaiy. Case.— Sergeant William Dougherty, Co. G, 101st Pennsj'lvania Volunteers, aged 34 years, was wounded at Plymouth, North Carolina, A])ril 20th, 1834, by a conoidal ball, which fractured the left parietal. A portion of the bone, two inches in length and one inch in breadth, was subsequently extracted, leaving the dura mater exposed. He ■was taken prisoner, and upon being exchanged was sent to Annapolis, entering the 1st division hospital on October 20th, 1864, suffering from partiid hemiplegia. He was ftuloughed on the 4th of November, and, at the expiration of his le.ave, November 22d, entered the hospital at Pittsburgh, Pennsylvania, where he was discharged the service on Februaiy 10th, 1865. He subsequently applied for a pension, and was examined by Dr. G. McCook, E.xamining Surgeon for Pensions, Pittsburgh, Pennsylvania, who rei)orts that there were substan- tial granulations from the dura mater. In 1838, Dougherty w'as a pensioner, his disability being rated total and tempoi’ary. On July 28th, 1839, I’ension Examiner P. B. Rice reports pai tial paralysis of the left side, and rates his disability permanent. Case. — Private Horace G. Conant, Co. D, 1st Ohio Vked healthy and was granulating. Absolute (juiet was enjoined, and taxation and light diet ordered; but the unfavorable symptoms evidently increased. On June 23d, ether was administered, and Assistant Surgeon John S. Hillings, U. S. A., made a crucial incision over the seat of injury, cut away a small portion of the sound bone with the bone-gouge forceps; then introduced the elevator into the opening, and removed the depressed portions of bone, comprising a circle of about three-fourths of an inch in diameter. Half an hour after the opeiuition it was found that sensibility had returned to the right arm, and that the right hand, which had previously been powerless, had recovered its strength. No untoward symptoms supervened, and the wound, which was kept open for two weeks to permit the free escape of pus, healed rapidly. On July 9th, while holding a candle and assisting in dressing a patient, he was suddenly seized with vertigo, and was immediately compelled to lie down. A full saline cathartic was given, and low diet ordered. No further cerebral symptoms occurred, and by the 20th he was j)erfectly convalescent. He was discharged August 5th, 1862. The case is reported hy Assistant .Surgeon .1. S. Billings, U. .S.. A. In September, 1867, Pension Examiner John F. Rat' reports that the vision in the left eye is impaired and intolerant of light. His disability is rated two-thirds and })ennanent. Case. — Lieutenant William Finn, Co. C, 14th Michigan Volunteers, aged 22 years, was wounded at the battle of Jonesboro’, Georgia, September Ist, 1864, by a conoidal ball, which fractured the- right ])arietal bone. He was on the same day admitted to the hospital of the 2d division. Fourteenth Corps, and on October 2.5th sent to the Officers’ Hospital at Lookout Mountain, Tennessee. During the treatment several spiculse of bone were removed. On November 5th, 1864, the wound had healed, and I'''inn received a leave of absence. He was mustered out on December 15th, 1864, on account of expiration of term of service, and was afterward pensioned on account of partial loss of sight in both eyes, with cephalalgia and dizziness. On March 26th, 186.5, Pension Examiner J. N. Brown rated his disability one-half and permanent. Case. — Sergeant Robert Hay.s, Co. E, 13th Tennessee Cavalry, aged 32 years, received, in an engagement at Bull's Gap, November 12th, 1864, a fracture of the cranium. He was probably treated in afield hospital until M.ay 17 th, 1865, when he was admitted to the Asylum Hospital, Knoxville, Tennessee. He was discharged on May 24th, 1865, and was pensioned. On October 12th, 1867, Pension Examiner C. Wheeler reports that the wound was succeeded b}- necrosis and exfoliation, a large piece of the right parietal bone, measuring three inches in length by one inch in width, having been removed. 'The patient suffers from violent pain in the head, with vertigo, dimness of vision, and other distressing symptoms. His disability is rated total. In July, 1868, Hays was a pensioner at eight dollars per month, his disability being rated total. Case. — Private August Heiinan, Co. K, 1st New York Cavalry, was wounded on picket, near Harrison's Landing, Virginia, August, 1862, by a piece of shell, which fractured the occipital and the ujiper edge of the right parietal bone. He was conveyed to Philadelphi.a, entering Broad and Cherry .Streets Hospital on the 7th. On the 28th, he was transferred to the S.atterlee Hospital. The wound was kept open to facilitate the discharge of pus, and the bowels were kt'jit in a relaxed condition by the administration of sulphate of magnesia. As he had severe pain in the head, on November 25th, the wound was enlarged and a tent was introduced. An abscess in the scalp, just below the wound, was opened on the 27th, and a compress applied. A sequestrum of bone, one-half by one-fourth of an inch, was removed on the 8th of December, and on the 13tli, several pieces were taken out. Again complaining of pain in the head, on the 26th, the wound was still further enlarged and another tent introduced. On January 23d, 1863, additional fragments of bone from both tables were removed. By the 31st, the sc.al]) wound had almost entirely healed, but the patient complained of pain at the seat of injury and gi’eat dizziness upon making any exertion. On February 1st, he was slightly feverish, and still complained of pain in the head. On March 17th, he was trams- ferred to the hospital guard for duty; but was re-admitted on the 19th, being unable to perform any duty. He was discharged from the service on March 30th, on account of general debility, irritability of tlie heart, and a constant headache. On .Iidy 25th, 1864, he applied for a pension and was examined by Dr. Charles Rowland, examining surgeon for pensions, Brooklyn, New York. The wound had healed, leaving a large indentation one inch in diameter, the scalp and mendu'anes alone protecting the brain. The applicant’s memory and vision in the right eye were impaired. 'The ca.se is rej)f)rted by .Surgeon Isaac 1. Hayes, U. .S. V. Ca.se. — Private Alexamler Kreiger, Co. D, 7th Iowa Volunteers, aged 19 years, was woundeper. Under this treatment he continued to improve until August 5th, when he was taken with fever, and his wound began to slough. The sloughing continued for several days, until it occupied a space two inches in diameter, but of slight depth. A weak solution of chlorinated soda was applied, and healthy granulations again sprung up. By October 1st the wound had almost cicatrized, though the brain pulsations were still visible. Pie was discharged from the service on December ICth, 1863. Pension Examiner J. W. Blackburn reported, January 6th, 1864, that there was persistent pain in the forehead, and weakness of sight and of intellect. A communication from the Commissioner of Pensions, January 2d, 1868, states that Euff is a pensioner, and that his disability is rated at three-fourths and permanent. Surgeon John Neill, U. S. V., reports the earlier facts of the case. Case. — Private Asbell A. Webster, Co. 1, 19th Michigan Volunteers, received, at the battle of Peach Tree Creek, Georgia, July 20th, 1864, a gunshot fracture of the parietal bone. He was insensible or delirious for a considerable time. Pie was taken to the hospital of the 3d division. Twentieth Corps, and on July 27th, admitted to Cumberland Hospital, Nashville. Six or eight pieces of bone, the largest three-fourths of an inch in length, were removed by Assistant Surgeon S. C. Ayers, U. S. V., from the cranium, exposing the dura mater. The wound became gangrenous, and a portion of the scalp, the size of a half dollar, sloughed away. On September 27th, the wound had healed, but sores would break out occasionally, especially in hot weather. On October 2;"th, he was sent to St. Mary's Hospital, and on December 10th, transferred to Harper Hospital, Detroit, Michigan, where he was discharged on January Gth, 1865. His mental faculties, especially his memory, were somewhat impaired, and the ('yesight was, to some extent, weakened, according to the report of Pension Examiner E. F. Stratton. In 1868, he was a pensioner at $8 per month, his disability being rated total and temporary. The pathological specimen is No. 4731, Sect. I, A. M. M., and was contributed by the operator. It consists of seven small fragments of bone, most of them from the outer table, but the larger comprising both tables and the intervening diploe. Foreign Bodies . — There were a few instances of recovery after removal of fragments of the. skull for gunshot fracture. Such extraneous substances as cloth or felt or leather were extracted with the bone splinters, having been driven in from the soldier’s hat or cap by the projectile. The missile itself, or portions of it, was of course often extracted with the bone fragments. The following series of six cases of this description can be collated with those referred to on pages 181 and 196. Other instances will be noted among the cases of removal of fragments of the skull that had a fatal issue : Case. — Private C. C. Blake, Co. G, 2d United States Sharpshooters, aged 23 years, was struck, at the battle of Antietam, Maryland, September 17th, 1862, upon the top of his head, by ball and buckshot, the missiles passing laterally over the sk>ill. Temporary symptoms of concussion followed, and after lying down fifteen or twenty minutes, the patient walked to a field hospital a short distance to the rear. His lower extremities, especially the left, were numb. The same sensation existed in a slight degree in the arms. The wound of scalp was two inches long by one inch wide, and fracture of the skull not suspected. The head was shaved and cold water dressings were applied. At the expiration of forty-eight hours, the man started and walked to Frederick, a distance of twenty miles. At the hospital there, a portion of felt from his hat and some hair were removed from the wound. The patient was then sent to Washington, and thence, on the 24th, he was again transferred and arrived at DeCamp Hospital, David’s Island, New York, on the 28th. A fissure of the right parietal bone, near the sagittal suture, was discovered. At the expiration of a week, an incision was made by Acting Assistant Surgeon E. B. Boot, and some small portions of the external table were removed ; the fissure was found to extend upward of two inches beyond the line of the incision. Five days subsequently portions of both tables were removed, exposing the dura mater to the extent of the size of a ten cent piece. The internal tablej which was found depressed about four lines, was elevated. The patient had suffered from neuralgic pain over his eyebrows, extending through the right temple to the wound. These pains and the numbness of the extremities disappeared after the elevation of the depressed bone. The patient was discharged from the service on November 3d, 1862. The wound had nearly healed, there being a few granulations at its centre. These moved with the pulsations of the brain. No head symptoms e.xisted. A cotnmunication from the Commissioner of Pensions, dated January 2d, 1868, states that Blake is a pensioner, and that his disability is rated total. The case is reported by Surgeon S. W. Gross, U. S. V. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 237 Case. — Sergeant Conrad Bryan, Co. H, 75th Oliio Volunteers, aged 25 years, was wounded at the hattlo of Chancollors- ville, Virginia, May 2d, 1863, by a conoidal ball, which fractured the left parietal bone. He was admitted to the hospital of the 1st division. Eleventh Corps, and on June 15th, transferred to the Carver Hospital at Washington; but on the 20th, sent to the Mower Hospital, Philadelphia. The wound at this time was very much inllamed and discharging freely. Flax-seed poultices and subsequently cold water dressings were applied. On June 30th, a small portion of bone, together with a piece of his cap, which had been driven into the wound, were removed. On July 24th, lie was transferred to the Seminary Hospital at Columbus, Ohio, the wound being nearly healed. Caries of the skull, how’ever, ensued, followed by attacks of epilepsy. The patient was discharged from service on April ICth, 1864. He is a pensioner, his disability being rated total and doubtful. The early history of the case is I’eported by Surgeon George Suckley, U. S. V. Case. — Private William H. Whitelaw, Co. D, 2d Connecticut Heavy Artillery, aged 25 years, was wounded at the battle of Winchester, Virginia, September 19th, 1864, by a bullet from a sphei ical case shot, which perforated and depressed the frontal bone in the median line. He also received a flesh wmund of the left thigh. He was at once admitted to the hospital of the 1st division. Sixth Corps, and thence conveyed, via Winchester and Slartinsburg, to the hospital at Frederick, where he arrived on October 12th. The missile and fragments of bone had been removed before admission. No head symptoms existed. On November 20th, a circular disc of bone, the size of a bullet, came out of the orifice and was removed by the patient. The piece had apparently been cut out by the ball, and had been driven upon the brain. On- the 28th, Acting Assistant Surgeon J. IT. Bartholf removed two pieces of jagged bone, each an inch in length, and one-third of an inch in width, and of an irregular shape. Simple dressings were applied. The patient did well and was, on February 25th, 1865, transferred to the Knight Hos- pital, New Haven, and on Jlay 15th, 1865, discharged from the service, by reason of surgeon’s cei'tificate of disability. On April 1st, 1868, Whitelaw was a pensioner; his disability being rated at three-fourths and temporary. Pension Examiner 11. Pierpont reported the man incapable of active exertion ; severe headache and roaring in the ears resulting from slight exercise. Case. — Private Joseph Aldridge, Co. A, 14th New York Volunteers, was wounded by a musket ball, which fractured the frontal bone, two inches above the left eyv. The missile split upon the edge of the bone, and remained fastened to it, recpiiring much force to remove it. He was admitted to the Satterlee Hospital, Philadelphia, on July 2Gth, 1862. No treatment is recorded, but ho recovered, and was discharged from the service August 25th, 1862. When examined for a pension by Pension Examining Surgeon H. B. Day, on December 4th, 1862, the wound had not yet healed. On May 16th, 1868, Examining Surgeon A. Churchill reported this pensioner’s disability as total, in consequence of vertigo and loss of memory. Dr. Churchill states that he removed the ball at the time of injury. Dr. Dfiy states that several fragments of bone had been removed, and that necrosed spiculae came away for several months subsequently. Case. — Private Louis Fuhr, Co. B, McClellan’s Dragoons, received, in an engagement near Cheese Cake Church, Virginia, May 4th, 1862, a fracture of the right parietal, from a musket ball, which struck near the upper posterior angle. On August 16th, 1862, he was admitted to De Camp Hospital, New York, whence ho was discharged and pensioned January 5th, 1863. Examining Surgeon F. Rubach, reports that “the ball lodged, and was extracted, with several spiculm of bone; that there was a deep depression of the skull at the seat of injury; that the patient was affected by vertigo and intense .headache, and to a great extent hindered from performing his usual labor.” C..VSE. — Private Timothy Pender, Co. F, 3d Michigan Volunteers, was wounded at the battle of Chancellorsville, Virginia, May 2d, 1863, by a round musket ball, which struck the right side of the frontal bone, about one inch and a half anterior to coronal suture, fracturing both tables of the bone. The missile was removed on the field. He was admitted to regimental hos- pital; on May 25th, sent to Judiciary Square Hospital, Washington, and on August 3d admitted to St. Mary’s Hosj)ital, Detroit, Michigan. The wound was in a bad condition, and on examination the probe revealed necrosed bone. A crucial incision was made, and a ring of necrosed bone one-fourth of an inch in width and comprising both tables was removed, which had completely encircled the original wound. The operation exposed the dura mater for a space as large as half a dollar. The injury gave the patient but little trouble; he recovered rapidly; was discharged November 3d, 1863, and pensioned. On August 12th, 1867, Pension Examiner J. B. Scovel reports this man to be subject to vertigo and severe neuralgic pain in the head. He rates his disability three-fourths and permanent. The forty following patients survived, with disabilities of various degrees. In nearly all, the brain was more or less seriously affected. Nine were insane. Many suffered from vertigo, headache, partial paralysis, inability to co-ordinate the action of the muscles, and other indications of injury of the nervous centres. This series completes the list of cases found on the records of recoveries after the removal of fragments in gunshot fractures of the skull, except cases of formal trephining and cases of cerebral hernia: Brannixger, William, Private, Co. I, 183d Ohio, aged 43 years. Franklin, November 30th, 1864. Shell fracture of right side of occipital. Nashville, Jeffersonville, Washington, and Philadelphia hospitals. Fragments of bone removed Aj)ril 22d, 1865. Wound healed May 19th. Discharged July 24th, 1865. August 15th, 1865, Examiner W. Owens, ]M. D., reports that the patient’s mind was seriously impaired, and that large fragments of bone were removed sifter he left the hospital. Germain, Henry J., Private, Co. K, 155th New York, aged 20 years. North Anmi, May 18th, 1864. Shell fracture of left parietal. Alexandria, New Tork, and Buffalo hospitals. Discharged June 8th, 186.5. Pension Ollice reports, November 8th, 1869, this pensioner partially insane, with defective sight and hearing, requiring a watcher. 238 WOUNDS AND INJURIES OF THE HEAD, Noukse, Gf.ohg]C U., I’l'ivate, Co. E, ‘23(1 Jlasisaclmsctts. Kinston, Docfinbcn' lltli, 186*2. Slioll IVactiiro of loft parietal near tlie ]iusterior superior angle. Foster Hospital, New Ilerne. Removal of fragments on the twenty-third day after reception of the injury, ^\ilh immediate relief to the stupor, cephalalgia, and convergent strahisiniis, which had existed from the date of the wound. Transferred to Wason Hospital, Boston, Fehruary 14th, 1863. Discharged and ])cnsioned A))ril 27th, 1863. January 16th, 1867, Examiner J. W. Spalding, M. D., rejiorts his disability as total on account of mental imbecility. Wagxei:, CuAliLES, I’rivate, Co. L, 1st New York Cavalry, aged 25 years. Pistol hall fracture of temjioral. Washing- ton, June 26th, 1865, Aimoi}* S(juare Hosjiital, Removal of fragments by Surgeon D. W, Bli,ss, U, S. V,, and ligation of posterior auricidar. Transferred to Ilarewood Hospital August 15th; discharged October l‘2tli, 1865, Pension Office reports, July 10th, 1868, disability total. Examiner P. S. Treadwell, December 13th, 1869, states that insanity is said to have ensued. Libby, Sami el B., I’rivate, Co. B, 17th Maine, aged 23 years. Spottsylvania, May 21st, 1864. Fracture over vertex by colloidal musket hall. Emory, Blackwells Island, and C’ony hospitals. Fragments removed; dura mater exposed; left leg partially )iaralyzcd. Discharged Deccndier 15th, 1864. April 26th, 1865, Examiner D. O. I’erry, M. D., reports complete left hemiplegia, mental ohtuseness, and severe pain in the head, and rates the disability three-fourths and somewhat amenable to treatment. September 30th, 1867, Examiner T. A. Foster reports that this man, after recxiveriug almost entirely from paralysis, had headache, temporary insanity, and epileptic fits. SiMMiNG, IlENiiY, Private, Co. F, 74th Pennsylvania. Cross Keys, June 8th, 1862. Gunshot fracture of upper angle of right parietal. Two inches of hone removed. Grafton Hospital, West Virginia. Discharged October 17th, 1864. January 3d, 1865, Examiner Cook, AI. D., reported this applicant’s mind deranged. In March, 1868, this man's disability was rated at three-fourths and temjiorary. Lew'is, Lucian, Private, Co. D, 69th New York, aged 18 years. Petersburg, September 30th, 1864. Fracture of occipital by conoidal musket hall. Corps, Judiciary Sipiare, and Satterlee hospitals. Bone splinters removed and dura mater laid hare. Discharged May 10th, 1865. Pension Office reports him a pensioner, and that he suffers from cephalalgia and impaired mind. Lovii, John, Private, Co. C, 57th Mas.«achusetts, aged 35 years. Petersburg, October 8th, 1864. Depressed fracture of left parietal near vertex by conoidal hall. Corps, Beverly, and Satterlee hospitals. Removal of large fragments. Discharged May 24th, 1865. July lUth, 1868, disability rated total by Examiner Oramel Martin, M. D. Byeks, Thomas P., Corporal, Co. F, 18th Ohio. Murfreesboro’, December 31st, 1802. Shell fracture near upper portion angle of left parietal. Fragments removed, leaving an opening an inch long and half an inch wide. Was hemiplegic for two months. Nashville hospital No. 14. Discharged April 29th, 1803. Examiner G. D. Hildreth rates the disability at three-fourths. Examiner J. 11. Brow'n pronounces it permanent, and says that there is depression over the youtliful corporal’s posterior fontanelle. Campion, Edwabd J., Corporal, Co. C, 20th Massachusetts, aged 31 years. Antietam, September 17th, 1862. Shell fracture of right temporal hone. Baltimore hospitals. Removal of sidculte of hone. Discharged March 10th, 1863. Examiner David Choate, M. D., reports, November ‘27th, 1863, that the patient is subject to vertigo, paljiitation, and morbid tvakefulness. Cleveland, William P., Private Co. K., 51st New York, aged 23 years, Petersburg, July 7th, 1864. Shell fracture of frontal. Bone splinters removed. Ninth Coips hospital. Fairfax Seminary Hospital. Discharged from service January 21st, 1865, and pensioned. Examiner Samuel Hutchings reports, March, 1866, that the bone is gone over the right eye, which is weak, and rates the disability at three-fourths. O'Connor, John, Pi ivate, Co. F, 86th New York, aged 27 years. Gettysburg, Jul^* 3d, 1863. Fracture of rigid parietal by conoidal ball. Mis.sile lodged, but was removed on the field. Gettysburg and Philadelphia hospitals. Removal of small fi’agmeid of bone July 9th. Symptoms of a typhoid character supervened, but were readily subdued. Discharged Sej)t('mber 19th, 1864. Examiner S. N. Pierce, M. D., June l*2th, 1867, reports that the pensioner has convulsions, followed by severe jiros- tration. Disability total and permanent. Dugan, I’atrick, Private, Co. A, 31st Massachusetts. Port Hudson, Louisiana, May, 1863. Gunshot fracture of cranium by a conoidal ball. Treated at barracks bospital. New* Orleans. Discharged November I'Jth, 1863. August 17 th, 1864, Examiner George C. Lawrence imports that a portion of the skull has been removed, and that the patient sufl'ers from pain in haad and dizziness. Disability three-fourths and permanent. Dygert, Edwin F., Private, Co. D, 114th Illinois. Jackson, Tennessee, January 14th, 1863. Fracture of frontal by a pistol ball, near the median line. Accide. dal. Jefferson and St. Louis hospitals. Fragments of skull removed. Discharged June 5th, 1863. Discharge paper states that he has “lost control over his locomotion, so far as direction is concerned. He cannot walk in a straight line, but moves in a zig-zag.” Examiner G. W. Cook subsequently reported that there was persistent pain at the point struck, with vertigo, and described the cicatrix as over the upper anterior angle of the right parietal. Cutler, Hiram, Private, Co. B, 2d New Hampshire. Bull Run, August 29th, 1862. Fracture of right temporal and parietal by conoidal ball. Douglas Hospital. Removal of a fragment of sejuamous portion of temporal one by one and a half inches. Discharged, December 14th, 1862. I’ensioned. Complains of giddiness. Niciiol.s, Hiram B., Private, Co. C, 11th Maine, aged 18 j’ears. Deep Run, August 16th, 1864. Fracture of right parietal at eminence. New York and Manchester hospitals. Discharged June 17th, 1865. September 14th, 1867, Examiner Charles W . Snow reports that several pieces of bone have been removed, leaving the brain exposed. The patient’s memory is impaired, and he suffers from vertigo and headache. Disability three-fourths. EEMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 239 Aixkn, \Vili.ia:\i H., Corporal, Co. K, llltli Illinois, aged 23 year.s. Fort McAllister, Savannah, Ueceinher loth, 18(54. Fracture of left i)arictal hy conoidal ball. Corps, Reanfort, and New York hosjiitals. Eeniovid of several fragments. Dis- charged May Gth, 18G5. July, 18G8, Pension Office reports his disability total and permanent. Gipple, Emanuel, Co. I, 93d Pennsylvania, aged 24 years. Sjiottsylvania, iMay 12th, 18u4. Shell fracture of temporal bone. Corps, "Washington, Philadelphia, and Harrisburg hospitals. Discharged June 13th, 18G5. June 1st, 18G7, Examiner John Levergood, M. I)., states that a piece of the outer table of bone has been removed. Disability one-half and jtermiinent. Rice, Hikam E., Sergeant, Co. E, 112th New York, aged 22 years. Fort Fisher, January 15th, 1865. Shell fracture of frontal bone. Mansfield, New Berne, and Buffalo hospitals. Removal of fragments of botie. Discharged July 13th, 1865. Exanuner G. \Y. Hazelton, March 29th, 18C6, rejtorts disability one-half and permanent. Math.\ny, CYilliam F., Private, Co. C, 19th Ohio, aged 30 years. Chickamauga, September 19th, 1863. Gunshot fracture of frontal bone. Field and Cleveland hospitals. Removal of several fragments of bone. Discharged July 27th, 1864. Examiner C. D. Griswold, M. D., reports, July 27th, 1864, that the pensioner is mentally and physically disabled. Meeeneu, Geoi:ge, Private, Co. K, 15th West "Yirginia, aged 18 years. Petersburg, April 2, 1865. Shell fracture of left parietal bone. Portsmouth and Baltimore Hospitals. Removal of fragment of bone one and a half by one inch. Discharged June 14th, 1865. Examiner "W. S. Bates, M. D., reports, September 14th, 1866, that the pensioner suffers from attacks of blindness and giddiness, and that he is unable to work for many days together. Hollis, John E., Private, Battery I, 1st Massachusetts Heavy Artilleiy, aged 20 years. Spottsylvania, May 19th, 1864. Stellate fracture of occipital bone, right side, by conoidal musket ball. Corps, Washington, Readville, and lYorcester hospitals. Removal of a fragment of bone through incision. Discharged November 20th, 1865. January, 1868, Pension Office reports his disability two-thirds and d(nibtful. Caries still existed. Jociiu.M, John J., Private, Co. B, 14th New York State Militia, aged 28 years. Gettysbui^, July 1st, 1863. Gunshot fracture of occipital and right parietal bones. Corps and New York hospitals. Removal of fragments from parietal and occipital bones. Discharged July 25th, 1864. Examiner Charles Rowland, M. D., states that the ])ensioner is unable to work, but that he will eventually recover. Disability three-fourths. Chapman, Joseph, Private, Co. K, 29th Wisconsin, aged 17 years. Compound fracture of right iiarietal bone by shell. Mobile, St. Louis, and Madison hospitals. About four square inches of bone -were removed. Discharged October 5th, 1865. May 8th, 1869, Examiner William T. Galloway reports that the pensioner has the appearance of an ejtileptic. Disability total. Rhoades, Benjamin F., Private, Co. I, 93d Pennsylvania, aged 24 years. Wilderness, May 5th, 1864. Gunshot fracture of both parietal bones, near latnbdoidal suture. Washington and Philadelphia hospitals. Removal of bone by Acting Assistant Surgeon L. E. Nordman. Discharged February 18th, 1885. March 4th, 1868, Examiner John Levergood reports that the pensioner is disqualified for manual labor. Fl.lvin, Edwakd H., First Lieutenant, Co. A, 14th New York State Militia. Spottsylvania, May 8th, 1864. Gunshot fi’acture of anterior edge of occipital at crown of head. Corps, AVashington, and New York hospitals. Removal of fragments of bone. Discharged June Gth, 1864. Examiner Charles Rowland, M. D., states. May 10th, 1865, that there is constant vertigo and partial loss of memory. AA'ook, John M., Private, Co. C, 107th Pennsylvania, aged 23 years. Fredericksburg, December 13th, 1862. Shell fracture of frontal, a little to the right of the median line. AA'^ashington and Philadelphia hospitals. January 25th, 1863, removal of fragments of bone, leaving brain pulsations visible. Discharged March 24th, 1863. January 2d, 1868, Pension Office reports his disability one-half and temporary. Nichols, AA^alteii, I’rivate, Co. K, 7th Alichigan, aged 24 years. Petersburg, .luue 22d, 1864. Gunshot fracture of fi'ontal bone. Corps and Philadelphia hospitals. Fragments of bone removed at various limes. Discharged January 5th, 1865. July 7th, 1868, Examiner S. S. Cutter, Al. D., reports that the pensioner suffers from dizziness, dimness of vision, and general prostration, and that his nervous system is very much affected. Disability total and permanent. AIcitPiiY, Owen, Private, Co. A, 6th New A’ork Cavalry. Chancellorsville, Alay 3d, 1863. Gunshot fracture of parietal •bone, .near coronal suture. AA^ashington and Baltimore hospitals. Removal of ])ieces of bone Alarch 7th, 1864. Discharged July 9th, 1864. Examiner .1. T. Burdick, AI. D., reports, Alay 18th, 1867, that there is constant vertigo. Disability one-fourth and temporary. AIcBitiDE, Samuel B., Private, Co. G, 140th Pennsylvania. Chancellorsville, Alay 3d, 1863. Gunshot fracture of frontal by conoidal ball. Point Lookout and Philadelphia hosj)itals. Sharp points of bone, and several fragments removed. Discharged December 18th, 1863. February 24th, 1864, Examiner J. R. AVilson reports that the pensioner has pain and heavi- ness in head atid along the cervical and dor.sal regions of the spine. Pollock, Aleked, Private, Co. G, 78th Illinois, aged 21 years. .Jonesboro’, September 1st, 1864. Shell fracture of occipital near protuberance. Nashville and Quincy hospitals. Fragments of bone removed. Furloughed, and while at home had his left leg fractured by a threshing machine. Leg amputated. Discharged Alay 18th, 1885. Examiners Robbins and Bassett rate his disability from wound of head total and permanent, on account of vtu'tigo and dizziness. Hannah, .JoSEni, Private, Co. B, 11th Alissouri. Corinth, October 3d, 1882. Gunshot fracture of frontal bone. St. John's Hospital, Paduc.ah, Kentucky. Removal of several spiculm of bone. Discharged February 3, 1883. E.xaminer Thomas S. Hening, M. D., reports that the pensioner has pains in the head, and that his nervous system is in a morbid atid excitable condition. 240 WOUNDS AND INJURIES OF THE HEAD, liussELL, Ci.EJiENT II., Private, Co. F, 37tli Massacliusetts, aged 19 years. Wilderness, May 5tli, 18G4. Gunshot frac- ture of cranium hy conoidal ball. Washington and Philadelphia hospitals. Removal of fragments of hone, leaving a large cavity in the skull. Discharged June 12th, 1855. December Gth, 18G7, Examiner C. L. Fisk reported that the j)ensioner sutlers from headache and dizzines.s, and is unable to bear exposure to heat or light. There is loss of memory, with cerebral excitement on taxing the brain to any great degree. Pfaff, Johx W., Lieutenant, Co. A, 101st Indiana. Chickamauga, September 20th, 18G3. Gunshot fracture of left parietal at the posterior superior angle. Corps, Chattanooga, and Nashville hospitals. Fragments of bone removed October 22d and 2Gth. Resigned February 21, 18G4. Examiner T. S. Butler, M. U., November 23d, 18G5, reports that the physical system of the pensioner is prostrated. Disability one-half and permanent. Morgan, Patrick, Private, Co. B, 57th New York. Fredericksburg, December 11th, 1832. Gunshot fracture of left parietal bone by conoidal ball. Corps and Washington hospitals. Removal of a fragment of bone one and a half by two and a half inches. Space partially filled with callus. Discharged April 25, 18G3. Examiner Alonzo Churchill, M. D., August 11th, 1868, reports that the pensioner suffers from dizziness and numbness of right foot and hand. Terry, Arthur, Private, Co. B, 8th Connecticut, aged 18 years. Antietam, September 17, 1832. Fracture of the left side of the frontal by a conoidal musket ball, and flesh wounds of the side and shoulder. Made prisoner, and paroled September 30th, and sent to Camden Street Hospital, Baltimore. Necrosed fragments of the skull removed from time to time by Acting Assistant Surgeon A. W. Colburn. Discharged December 19th, 1832. In May, 1864, Examiner R. Strickland reports the wound firmly healed, and rates the disability at one-third and temporary. McKatheran, Martin, Private, Co. I, 32d Massachusetts. Fredericksburg, December 13, 1832. Gunshot fracture of skull at vertex. Corps and W''ashington hospitals. Removal of fragments of bone. Discharged February 21st, 1863. Exam- iner George Stevens, M. D., reports, October 15th, 1863, that the pensioner has constant vertigo, and periodical pain. Bullock, Alfred W., Sergeant, Co. C, 3d Massachusetts Cavalry. Sabine Cross Roads, April 8th, 1864. Gunshot fracture of frontal bone, left side, by conoidal ball. New Orleans and Readville hospitals. Removal of exfoliated bone. Discharged December 19th, 1864. May 9th, 1866, Examiner W. II. Page, M. D., states that the man suffers from dizziness and pain, especially on stooping. Van Valkenburg, C.vlvin, Private, Co. I, 91st New York, aged 22 years. South Side Railroad, April 1st, 1865. Fracture of frontal by musket ball near junction of coronal and sagittal sutures. Fifth Corps, Lincoln, and Ira Harris hospitals. April 11, fragments removed by Surgeon J. C. McKee, with immediate relief of the symptoms of compression. ^ The patient was discharged September 11th, 1865. In 1835, Examiner W. H. Craig reported that this pensioner suffered from giddiness and pain in the head; and in July, 1868, the Pension Office reports that he is still a pensioner, his disability rated at three-fourths and permanent. Leap, John C., Private, Co. G, 28th New Jersey, aged 43 years. Fredericksburg, December 13th, 1832. Gunshot fracture of frontal bone by round ball. Washington and Philadelphia hospitals. Spiculie of bone removed by crucial incision. Difficulty of mictm-ition, and pain in temples and nape of neck. Discharged March Gth, 18G3. September 30th, 1869, Examiner James E. Armstrong, M. D., reports that the missile still remains within the cavity, and is supposed to be near the base of the brain.- His memory and sight are impaired, and he is subject to attacks of vertigo and syncope. The following series of abstracts refers to patients who recovered after gunshot fractures of the skull treated by the removal of fragments ; but whose names, at last accounts, had not been placed upon the Pension Roll ; Case. — Corporal Maurice Fitzgerald, Co. E, 28th Massachusetts Volunteers, aged 25 years, was wounded at Fort Stead- man, Virginia, March 25th, 1865, by a conoidal ball, which comminuted and depressed the left parietal bone one and a half inches to the left of the median line. On the following day, he was taken to the hospital of the 1st division. Second Corps, thence was conveyed to Wash- ington, and admitted to the Emory Hospital on the 30th, being in a state of insensibility and unable to articulate or raise the right hand ; his tongue inclined to the right side, when protruded. His pulse was slow but strong. Being placed under the influence of chloroform on March 31st, Surgeon N. R. Moseley, U. S. V., enlarged the wound, removing numerous portions of the cranium, with pieces of the ball. On April 2d, jiills of calomel and extract of henbane were administered to produce slight ptyalism. On April 15th, the patient was able to walk and speak, and had proper use of all parts of the body. On June 3d, he was transfeiTcd to the Mower Hospital at Philadelphia; thence, on July 24th, was transferred to Massachusetts. The pathological specimen was contributed, with the history, by Surgeon N. R. Moseley, U. S. V., and is figured in the adjacent wood-cut. This soldier was discharged the service, July 22d, 1865. His olaim for a pension is pending. Case. — Sergciant Brayton C. Bailey, Co. H, 84th New York Volunteers, aged 24 years, was wounded at the second battle of Bull Ruu, August 30th, 1832, by a conoidal ball, which fractured both tables of the cranium at the right frontal eminence. ’ .See photograph 9, Vol. HI, of Contributed Surgical Photographs, A. M. M. ^ See the series of nineteen cases on p. 193, ct seq., with which this would have been grouped had the evidence been more satisfactory. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 241 Appareiitly the ball had split on tlie edge of tlie hone, and one part of the missile had passed into the cranial cavity. The ])atient was insemsible for several days. On September dd, he was admitted to the Sixth and Master Streets Hospital, Philadelidiia, where he remained nnder treatment for four and a half months. Thence he was transferred to the Mower llospital. Two months subsequently, his wound was probed and pieces of dead hone from both tables were removed. The wound discharged freely, hut gradually closed; and the patient was discharged from the service on April ‘27th, 18G3. Dr. G. S. M'alker, of llion, Herkimer County, New York, writing under date of JMarch Gth, 18GG, says that the scar is about an inch and a half in dianieter, and gradually depressed from its outer margin toward the centre. There seems to he a deficiency of bony tissue for about half an inch about the centre. The depression at the centre of the scar is about five-eighths of an inch. The skin over the scar has not yet assumed its natural color but is of a bluish tint. The jiatient’s health had been good ; hut any severe exercise, mental or physical, would induce dizziness and a severe headache. At times, when perfectly quiet, he is attacked with a sharp pain, as if, according to his description, his “ brain was being pierced with a pointed instrument at a point oj)posite the wound;” and at such times, any little jar of the head makes the pain so severe that it almost blinds him. Aside from these attacks, his health is good. He is not on the Pension Roll. Case. — Private William L. Copeland, Co. A, 1st Mississippi Marine Brigade, aged 21 yeai’s, was wounded, July 4th, 18G4, at Coleman’s Cross Roads, near Rodney, Mississijqii, by a musket ball, which entered the cranium two inches directly above the outer canthus of the right eye, fractured tin* frontal bone and lodged in the wound. The missile and fragment of bone were removed on the following day. He was conveyed to Vicksburg, and entered McPherson Hospital on the Gth. Anodynes were administered internally, and cold and emollient applications made to the wound. On the 1st of September, another piece of hone was removed, and on the Gth, a third fragment was removed by Surgeon E. Powell, 72d Illinois Volunteers. The wound continued very painful until after the removal of the last piece of detached bone, when it healed rapidly. He recovered sufficiently to act as nurse, but had lost his voice. When returned to duty on December 4th, 18G4, he had recovered his voice He is not a pensioner. ) •'' Case. — Private Louis Miller, Co. D, 4Gth New York Volunteers, aged 34 years, was wounded at Petersburg, Virginia, June 30th, 1884, by a shell, which fractured the cranium near the superior parietal angle. He was at once admitted to the hospital of the 3d division. Ninth Corps, where fragments of the parietal, temporal, and frontal bones were removed, and the flaps united by a slight suture. On July 3d, he was sent to Washington, and entered Ilarewood Hospital on the 4th, being somewhat uneasy, but not complaining of pain. The ))ulse was slightly accelerated, tongue clean, and appetite good. U)ion removing the suture the wound was found to be full of maggots. The dura mater was exposed for a space about three inches in circumference, and of a greenish color ; the pulsations of the brain were distinctly visible. On the Gth, the flaps became gangrenous, and were entirely destroyed. The wound was healthy, but the external layer of the dura mater was sloughing. Flax-seed poultices were applied. The upper margin of the wound gi-anulated finely. An incision was made, and a dressing of chlorinated soda was employed. The granulation of upper margin continued healthy. On July 28th, secondary hatmorrhage occurred from the left temporal artery, which was ligated ; about ten ounces of blood having been lost. From that time the wound assumed a healthy appearance. Small pieces of bone wore removed as they became detached. Partial necrosis of the parietal bone supervened. The necrosed portion, consisting of both lamellaj, was removed. The discharge now became less copious, and the wound healed rapidly. Miller was furloughed on November 3d, 18G4, returned on the IGth, and was discharged from the service on July 25th, 18G5, being, at the time, in very good health. He is not a pensioner. The case is reported by Surgeon R. B. Bontecou, U. S. V. Case. — Private William Furlong, Co. G, 153d Pennsylvania Volunteers, aged 33 j'ears, was wounded at the battle of Gettysburg, Pennsylvania, July 1st, 18G3, by a fragment of shell, which struck the external angular jirocess of the frontal bone and carried away the left superciliary ridge. The wound was about one and a half inches in width, and four inches ui length. He was insensible only for a short time, and, considering the serious nature of the injury, it is remarkable that he walked with his companions to a sand-bank, and actually dug therefrom, with his own hand, the fragments of the shell which inflicted the injury. He received little or no treatment until July IGth, when lie was admitted to Cotton Factory Hospital, Harrisburg, Pennsylvania. Tepid water was injected into the wound, and several spicnlaj of bone were removed from the substance of the brain. One piece, however, was not removed and still remains, as it was feared that haimorihage would follow ; besides, the conscious condition of the jiatient did not warrant further interference. The jiulse throughout I’emained normal, and sleep natural. On August 10th, the patient was cheerful, and healthy granulations had commenced. There was considerable tume- faction of the left eye, and inability to move the lids. On forcibly opening them the pupil was found dilated ; the intellect was unimpaired. On August 18th, the pulsations of the brain were still manifest, although granulations were nicely closing the wound. During August and September, scales and spiculm of bone which were forced to the surface by the granulations, were removed. He was discharged on September 14th, 18G3. He is not a pensioner. The case is reported by Acting Assistant Surgeon Lewis Post. Case. — Private Thomas B. White, Co. K, 94th Ohio Volunteers, was wounded at Murfreesboro’, Tennessee, Decemlxu- 31st, 1862, by a conoidal ball, which struck the posterior angle of the left parietal bone at a point equidistant one inch from the sagittal and lambdoid sutures, passed through the posterior portion of the left hemisphere of the cerebrum, and lodged upon the tentorium cerebelli, a distance of thi-ee inches from point of entrance. He became completely insensible, but recovered within an hour, and, with the aid of an assistant upon either side, walked to the tield hospital. Careful examination showed that the hall was not impacted in any of the structures ; it was therefore removed, together with a few loose spiculm of hone. During the opertition some brain substance escaped. Shortly afterward he became insensible, and remained so for three weeks. When consciousness returned, he was unable to move his right arm or leg, was very deaf, especially in the right ear, complained of loss of vision of right eye, and could with difficulty sj)eak. lie improved very slowly, and at the erjd of Aju il, 18G3, could standalone. He was discharged April 28th, 18G3. In August, 1863, he looked well, and could walk without difficulty; the 31 242 WOUNDS AND INJURIES OF THE HEAD, motion of his ann was yet imperfect, hut the wound was almost healed. Small spiculae of hone, too finnly attacln^ to be removed at the date of the first operation, had from time to time been loosened and detached by the efi'orts of nature. No pension granted. Case still pending. Case. — Private Patrick Finnegan, Co. I, Gist Now York Volunteers, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a round ball, which struck the skull obliquely, fractuiing both tables of the right paiietal bone, just above the superior edge of the temporal bone. The ball split ; one-half escaped, the other half, flattened, lodged between the tables. He was taken prisoner, and remained in the hands of the enemy until May ICth, whin he was admitted to the hospital of the 1st division, Second Corps. The left arm and leg were paralyzed, and a number of pieces of bone were fixed in the substance of the brain. Two or three ounces of pus, mixed with portions of brain, escaped. The bone around the orifice was denuded on outer and inner surfiices. On about May 21st, spiculas of bone and portion of ball were removed by Surgeon C. S. Wood, G6th New York Volunteers, when the paralysis abated. On June 14th, he was admitted to the hospital at PointLookout, Maryland. A number of small spiculae of bone escaped from time to time, but the healing process continued without interruption. The patient's mind appeared somewhat debilitated, and his hearing was imperfect, but ho was in excellent spirits, sleeping and eating well. He was discharged on June 10th, 1865. Case. — Private Henry R. Cox, Co. D, 47th New York Volunteers, aged 23 years, was wounded at the battle of Olustee, Florida, February 20th, 1834, by a conoidal musket ball, which fractured the right side of the frontal bone, without apparently causing a depression. He was admitted to the ho.spital at Jacksonville, Florida, February 22d, 1864, and sent on the 25th to Hilton Head, South Carolina, where several fragments of depressed bone were removed, and simple dressings applied to the wound. In May, 1864, he was transferred to New Y’’ork, and on the 12th admitted to the St. Joseph Hospital, Central Park. He recovered, and was mustered out on June 10th, 1865. He is not a pensioner. •<- Case. — Private Peter Englehart, Co. E, lOth Wisconsin Volunteers, aged 25 years, was w'ounded near Kenesaw Mountain, Georgia, June 18th, 1864, by a piece of shell, which struck the os frontis at the junction of the frontal and left parietal bones, causmg a slight depression. He received in the same engagement a perforating flesh wound of the left leg four inches below the knee. He w’as at once admitted to the 1st division. Fourteenth Corps, field hospital ; on June 29th, sent to No. 1, Chattanooga; and thence, on July 12th, transferred to Hospital No. 8, Nashville. On July 19th, he was again transferred to the Jelferson Hospital, Jeffersonville, Indiana, and thence, per steamer R. C. Wood, sent to the Simons Hospital, Mound City, Illinois. The records of the latter hospital state that the patient remained insensible for ten days subsequent to the injury, and that two small pieces of bone were removed. The wound healed. On September 24th, Englehart was admitted to the hospital at Keokuk, Iowa, and discharged from the service on October 13th, 1864. He is not a pensioner. Case. — Private Charles W. Webb, Co. B, 144th New Y’’ork Volunteers, aged 18 years, was wounded at Pocotaligo, South Carolina, December 6th, 1834, by a musket ball, which fractured and depressed the left parietal bone. He was on the same day admitted to the regimental hospital, and transferred, on December 9th, to the hospital at Beaufort, South Carolina. He had lost the power of speech, and was hemiplegic on the right side. A small portion of the brain substance, which protruded, had sloughed away, exhibiting clearly the depressed portion of bone. On December 15th, Surgeon John Trenor, jr., U. S. V., re- moved several fragments of the outer table and elevated the inner table. W’ater dressings were applied. The wound was kept thoroughly cleansed by syringing with water and solution of chlorinated soda, and the bowels were kept laxative by cathartics. Ho improved gradually, regained his speech, and recovered by degrees the use of the right arm and leg. Ho was transferred on January 23d, 1865, and entered McDougall Hospital, Fort Schuyler, New York Harbor, on January 29th. On April 28th, he was transferred to Troy, New York, where he remained until June 12th, 1865, when he was discharged from the service. He is not a pensioner. The case is reported by the operator. Case. — Private August Wiosner, Co. A, 50th Pennsylvania Volunteers, aged 25 years, was wounded at Petersburg, Virginia, June 28th, 1834, by a conoidal ball, which fractured and depressed the left parietal bone between the parietal eminence and the lambdoidal suture. He Avas conveyed to the field hospital of the 3d division. Ninth Corps, where the depressed portion was elevated by Surgeon Wells B. Fox, 8th Michigan Volunteers. The patient was sent to City Point, and thence, by hospital steamer, to the McDougall Hospital, Fort Schuyler, Ncav Y'ork Harbor, which he entered on July 10th. He remained until August 18th, when he was furloughed, and ordered to report at the expiration of his leave to tli'e medical director at Philadelphia. He entered Mower Hospital on September 20th, and Avas discharged from the service on July 14th, 1865. He is not a pensioner. Case. — Sergeant John Walton Hartley, Co. I, 61st Ncav Y’’ork Volunteers, Avas, on June 12th, 1662, admitted to TAventy- second and Wood Streets Hospital, Philadelphia, Avith a gunshot Avound of the head. The missile had removed the external table of the right parietal bone and depressed the inner table. He Avas furloughed, and Avhile at his home, the depressed portion of the inner table Avas removed. He Avas discharged on Januaiy 28th, 1863. His left side Avas partially paralyzed. Not a pensioner. Case. — Private John Duffy, Co. A, 28th Massachusetts Volunteers, received, at the battle of Bull Run, Virginia, August 31st, 1862, a gunshot fracture of the external table of the left parietal bone. He Avas admitted into the Carver Hospital, Wash- ington, September 7th; on December 10th, he Avas furloughed ; and Avas discharged the service February 6tli, 1863. On May 21st, 1863, Pension Examiner 6. S. Jones reports this man to have a depression in the skull from Avhich loose bone has been removed, and to be suffering from cephalalgia and A’ertigo. He rates his disability one-half and doubtful. On April 13th, 1865, Pension Examiner J. T. Galloupe reports this man to have re-enlisted February 28th, 1864, as a private in the 29th Massachu- setts Volunteers; and to have done full duty from that time until the date of his report, Avhen the man Avas a paroled prisoner of Avar, his disability being removed. REMOVAL OF FEAG^^IENTS AFTER GUNSHOT FRACTURES OF TtlE SKULL. 243 Case. — Corporal Patrick Farrell, Co. C, 140tli New York Volunteers, aged 2o years, was wounded at the battle of Spott- sylvauia, Virginia, May 9tli, 1834, by a conoidal musket ball, which fractured the skull. He was at once admitted to the 1st division. Fifth Corps, hospital, and thence, on the 12th, sent to the 3d division hospital at Alexandria. A few small scales of hone were taken from the wound by forceps, but no untoward symptoms manifested themselves in the progress of the case. On June 6tli, the patient was furloughed. He w'as discharged the service September 2d, 1834. On February 25th, 1837, Pension Examiner H. T. Montgomery reports this man to bo perfectl}' healthy looking, and complaining only of nervousness. He does not think him disabled by the wound. McQueeny, John, Private, Co. I, 2d Connecticut Heavy Artillery, aged 18 years. Cedar Creek, October 19th, 1804. Gunshot fracture of zygomatic process of left temporal bone. Corps, Philadelphia, and New Haven hospitals. Portions of zygoma were removed. Discharged June 20th, 1834. Not a pensioner. Mosbery, Alexander, Private, Co. E, 40th New York, aged 22 years. Petersburg, March 25th, 1865. Gunshot fracture of cranium one inch below squamous suture, right side. Corps, Washington, and Whitehall hospitals. Removal of depressed bone by incision. Discharged July 3d, 1865. Not a pensioner. B.,vrr, Tiiojias T., Co. H, 33d Ohio Volunteers, aged 24 years. Chickamauga, September 20th, 18631 Fracture of skull below' and to the left of the occipital protuberance by shell. Treated in Confederate hospitals at Ringgold and Richmond. Paroled March 6th, 1834, and admitted to hospital at Annapolis Junction. Ten fragments of bone removed. Discharged September 20th, 1864. Not a pensioner. McCormick, William C., Private, Co. A, 80th Illinois, aged 30 years. Atlanta, August 20th, 1864. Gunshot fracture of fi’outal bone. Atlanta, Chattanooga, and Nashville hospitals. Removal of fragments of bone. Musteredout June 10th, 1865. Not a pensioner. Nutze, Charles F., Sergeant, Co. B, 6th Pennsylvania Cavalry, aged 32 years. Culpeper Court-house, August 1st, 1863. Gunshot fracture of external angular process of temporal. Corps and Washington hospitals. Fractured bone removed. Discharged March 3d, 1834. Sight of left eye lost. Not a pensioner. Murgatroyd, George M., Captain, Co. A, 68th Pennsylvania, aged 32 years. Jacob’s Ford, November 27th, 1863. Gunshot fracture of zygoma. Alexandria hospital. Removal of spiculm. Recovered; transferred to Co. 1, 186th Pennsylvania Volunteers, and mustered out August 15th, 1865. Not a pensioner. Wassdre, Louis, Corporal, Co. B, 27th Michigan, aged 22 years. Petersburg, July 30th, 1864. Depressed shell fracture of left parietal. Removal of fragments of skull at Ninth Corps hospital, by Surgeon W. C. Shurlock, Slst Pennsylvania Volunteers. Sent to DeCamp Hospital, and discharged for disability, February 1st, 1865. McCall, James, Corporal, Co. I, 144th New York, aged 23 years. Pocotaligo, December 9th, 1834. Fracture of left side of frontal by conoidal musket ball. Beaufort, Fort Schuyler, Troy, and Albany hospitals. Removal of fragments by Surgeon Hendrickson. Sent to be mustered out, June 17, 1865. Bartholojiew', Francis T., Corporal, Co. C, 1st West Virginia Cavalry. Culpeper, November, 1833. Gunshot fracture of frontal bone. Removal of fragments of bone. Discharged at Wheeling. February, 1867, Assistant Surgeon C. R. Greenleaf, U. S. A., examined the man and states that the wound has entirely healed. Not a pensioner. Grieein, Albert C., Private, Co. F, 107th Pennsylvania, aged 21 years.'- Gettysburg, July 1st, 1863. Gunshot fracture of right parietal bone by conoidal musket ball. Corps, Philadelphia, and Alexandria hospitals. Removal of small frag- ments of bone by forceps. Discharged December 29th, 1864. Not a pensioner. Roe, John, Private, Co. D, 31st Illinois, Jackson, September, 1862. Gunshot fracture of frontal and parietal bones by conoidal musket ball. Memphis and St. Louis hospitals. Fragments of both tables removed. Discharged February 3d, 1863. Not a pensioner. Laeitte, Charles, Sergeant, Co. A, 40th New Jersey, aged 36 years. Middletow'n, November 15th, 18(54. Shell fracture of left parietal bone ; also fracture of lower four ribs. AVinchester, Frederick, ’and Washington hospitals. Removal of fragments of bone. Discharged May 30th, 1865. Not a pensioner. O'-Rorke, John, Private, Co. C, 10th New York, aged 21 years. Spottsylvania, May 10th, 1864. Gunshot fracture of cranium. Washington hospitals. Bone splinters removed. Discharged. Not a pensioner. Dorr, Joseph, Corporal, Co. C, 12th Connecticut, aged 22 years. Cedar Creek, October 19th, 1804. Stellate fracture of parietal bone by conoidal ball. Frederick and Baltimore hospitals. Removal of depressed bone. Discharged September 21st, 1865. Not a pensioner. Twenty-four patients, enumerated in the following series, recovered after removal of fragments of the skull, produced by gunshot fractures, and were either furloughed, retired, released, or exchanged. The first three cases were complicated by erysipelas : Case. — Private Galoin Forest, Co. G, 8th North Carolina Infantry, aged 18 years, was woundc’d at the battle of Cold Harbor, Virginia, Jlaj- 31st, 1864, by a conoidal hall, which entered one inch above the left zygomatic process, passed through the left orbit, destroying the eye, and emerged from the inner wall of the right orbit, carrying with it the right eye. He was 244 WOUNDS AND INJUEIES OF THE HEAD udinitted into the geueral field hospital on June ‘2d, and on the 10th he was transferred to the Lincoln Hospital, Washington, in a delirious condition. Erysipelas had attacked the wounds, and he suftered considerably. Five spiculat of bone were removed daily. Simple dressings were used. Tonics were administered. The wounds gradually liealed. There was a loss of the senses of taste and smell ; but that of taste became almost entirely restored. He was transferred to the Old Capitol Prison, for exchange, on October 1st, 1864. Assistant Surgeon J. Cooper McKee, U. S. A., reports the case. Case. — P rivate J. W. Taylor, Co. A, 34th Virginia Regiment, aged 33 years, received, on May 20th, 1864, a gunshot fracture of both tables of the occipital bone, near the posterior fontanelle. He was, on June 20th, admitted to Chimborazo Hospital No. 2, Richmond, Virginia. On admission, the wounds were erysipelatous ; but some loose spiculm of bone were removed, and the injury soon assumed a healthy appearance, and on July 24th the patient was allowed to go home for GO days. Case. — Piivate 71'. C. Allen, Co. E, 1st Georgia Infantry, aged 22 years, was admitted into the Confederate hospital at Charlottesville, Virginia, on August 27th, 1862, with a gunshot wound in the scalp, about an inch and a half above the zygomatic process, and half an inch anterior to the left ear. The wound was suppurating slightly, but there were no symptoms of serious injury to the skull or brain. The patient was walking about as if nothing w’as the matter, and eating heartily. The probe could not be introduced to the skull, the track of tlie wound being closed, probably by a firm clot, which had not been discharged by suppurative action. At the next examination, four or five days after his admission, the probe readily passed downward under the temporal muscle to the bone, which was found fractured and depressed, but to what extent could not be ascertained, excep. by cutting, wdnch recpiired a division of the swollen and putty integument, and the temporal muscles in the vicinity of the fracturet A consultation wuis held, and an operation determined upon. The missile, a common musket ball, had been removed through the wound by a surgeon, shortly after the reception of the injury. On the 2d of September, the patient was chloroformed, and J. L. Cabell, surgeon in charge of hospital, made a crucial incision, two inches in length, in the scalp, and in doing so it was found necessary to ap23ly ligatures to the temporal artery and one of its branches. When the flaps were dissected up, the fracture was found to be quite irregular, and as large as a twenty-five cent piece, while the fragments were driven in and pressing upon the dura mater. With considerable difficulty, thirteen pieces of bone were removed with the forceps, several of these being quite large, and grooved on the inner surface, showing the seat of injury to be directly over the middle meningeal artery. After removing all the pieces that could be felt with the fingers, the parts were drawn together by strips of adhesive plaster, and the wound was dressed with lint. The next day slight erysipelas made its appearance around the wound, involving the car and side of the face, and nearly closing the left eye. Muriated tincture of iron, ten drops every two hours, were ordered, and the patient kept 25erfectly quiet. lu twenty-four hours the erysipelas had disappeared, and from the third day after the oireration, no unpleasant symptoms occurred, the wound suppurating finely, and closing rapidly, and this, too, with the patietit going about the liosjjital more or less every day, as it was found impossible to keep him in bed. The treatment after the disapi)eai'ance of the erysipelas, consisted solely in the application to the wound of wet lint twice a day, and keeping it clean. By the 18th of Sep- tember the wound had healed, except at the intersection of the two incisions. A small opening the size of a imobe existed at that point, through which a slight discharge was kept up. The patient was discharged from the service on February 3d, 1863. The case is reported by Assistant Surgeon B. W. Allen, F. A. C. S. Case. — Captain T. J. Hadley, Co. A, 3d Arkansas Regiment, received, near Petersburg, Virginia, July 16th, 1864, a gunshot fracture of the cranium, just in front of the junction of the occipital with the parietal bone. He was, on the following day, admitted to a hospital at Petersburg, and thence sunt to Howard Grove Hospital, Richmond, where a section of both tables, one and a half inches in diameter, was removed. There was i)aralysis of the left side, from which the patient never fully recovered. He was retired from the service on December 13th, 1864, being permanently disabled for field service. Case. — Sergeant S. J. Bavgston, Co. I, 45th Georgia Regiment, was wounded at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a fragment of shell, which fractured and depressed the outer table of the occipital bone on the right side. At different periods, several fragments of bone were removed with elevator and forceps. Loss of power in the extremities, headache, and vertigo followed, and, subsequently, spasmodical mental derangement supervened. He was admitted to the De Camp Ho.spital, David’s Island, New York Harbor, July 19th, 1833 ; thence transferred to Bedloe’s Island, October 24th ; and on January 10th, 1884, sent to the Hammond Hospital, Point Lookout, Maryland. The wound had healed, and presented a depression about one and a half inches long by half an inch wide. His condition imjn’oved slowly, and in March, 18G4, he had only occasional manifestations of mental aberration, with a decided disinclination to converse. On the 10th, he was sent to the provost marshal, and on the 14th was transferred for exchange. The case is reported by Acting Assistant Surgeon W. F, Buchanan. Case. — Private McCleary was shot on October 19th, 1863, while trying to escape from prison at Point LookoiV, Maryland. The missile, a pistol ball, struck the cranium just above the coronal suture, left, side, causing a triangular-shaped depression of both tables, and glanced. He also received wounds of the liver and lung. On October 24th, he was admitted to the hosjrital at Point Lookout. There were no unfavorable symptoms; the wounds were filthy, but perfectly healthy ; the secretions normal. It was stated that the patient had remained comatose for two days after the reception of the injury, but on admission he was perfectly rational and cheerful, and suffered no pain. The pulsations of the brain were visible. The wounds were cleansed, and simple dressings .applied. In February, 1864, a piece of the skull, which had become detached, was removed. The wound healed rapidly, and April 27th, 1864, the man was sent to the provost marshal for exchange. For two or three weeks before his exchange, he had ijerformed the duties of a nurse in the ho.spital. Case. — Private William B. liobertson, Co. E, 48th Alabama Regiment, aged 26 years, received, at the battle of Antietam, Maryland, September 17th, 1862, a gunshot depressed fracture of the cranium at or near the right temporal ridge. No paralysis existed. He was admitted into the hosjiital at Charlottesville, Virginia, where he was ojter.ated upon on October EEMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 245 lOlli, at which time lie had heeouie much enfeebled. The scalp was imderiiiined, the bone denuded around the fractured portion, and large quantities of pus were discharged daily. During the operation it was found necessary to use lley’s saw to release a large fragment of depressed bone. No unpleasant symptoms followed, and the j)atieut finally i'ecov(Ted. with a large depressed cicatrix, lie was discharged on March 23d, 18G3. The case is reported by Assistant Surgeon 11. W. Allen, 1*. A. C. S. Case. — Private (!. H. Sanford, Go. A, 8th Geoigia Regiment, aged 27 yeai's, received, on August 28th, 1862, a gunshot depressed fracture of both tables of the superior jiortion of the left parietal bone. There! was paralysis of the right side of the body, but the mind was clear. Ho was admitted into the Confederate hosj)ital at Charlottesville, Virginia, and on September 23d was operated upon. All the pieces of bone were removed. Ten daj’s after the ojiera’tion, the paralysis had entirely disaiipeared. The patient inqn’oved rapidly, was furloughed soon after, and is believed to have recovered entirely. The case is reported by Assistant Surgeon B. W. Allen, P. A. C. S. Case. — Pi-ivate James I). Ferris, Co. II, 18th Virginia Regiment, aged 18 years, was wounded at Hatcher’s Run, Virginia, Apill 1st, 1835, by a conoidal ball, which fractured the j^arietal bones, the fracture extending from the coronal suture backward one and a half inches over the sagittal suture. He was taken piisoner, admitted into the hospital of the 3d division, Fifth Corps, and thence sent to the Lincoln Hospital, Washington, on the 8th. On Aiwil 20th, Surgeon J. C. McKee, U. S. A., removed several fragments of depressed bone. The wound healed rapidly, and the patient's general health remained excellent. On the 14th of June, he was released upon taking the oath of allegiance, having entirely recov’ered. The case is reported by the operator. Surgeon J. C. iMcKee, U. S. A. Vide Photographs of Surgical Cases, A. M. M. Vol. Ill, No. 17. Case. — Major N. M. Xorris, 14th Tennessee Regiment, aged 30 years, was wounded at the second battle of Bull Run, Virginia, August 30th, 1862, by a musket ball, ^vhich struck the left side of the cranium a little in front of and on a level with the parietal protuberance, fractured the skull for about two and a half inches longitudinally and about one inch across, and lodged. The wound of scalp was still more cxten.sive ; the membranes were laeei’atcd, and brain substance exuded. He was not examined by a surgeon on the field, as no one who saw him thought he would live beyond a few hours. The day following, a large piece of bone was removed, by his brother, ^vitll his fingers. The patient was perfectly unconscious for five days, and when, at the expiration of that time, consciousness returned, he was found to be paralyzed on the right side of the body. Three months after the reception of the injury, the ball and a large piece of bone were removed. Several smaller pieces were taken away or discharged at intervals, the last of them about four months after he was wounded. His general health had not been good for several months prior to the reception of the injury, having suffered from chronic diarrhoea. By July 1st, 1803, his ])aralysis was slowly getting better, and he was able to walk about with the assistance of a crutch. He could speak oidy with gi’eat difficulty, frequently forgetting wdiat he was talking about, and stated that he could not read anything fi’om inability to connect the woi-ds into a sentence. His appetite was good, and general health much improved. The wound was not entirely healed. There was a large cicatrized surface, covering a depression two and a half inches long and three-fourths of an inch wide, beneath which, when the head was inclined forward, the pulsations of the brain could be distinctly seen and felt. The case is reported by Assistant Surgeon B. W. Allen, P. A. C. S. Case. — Sergeant John Moore, Co. E, 38th Alabama Regiment, aged 24 years, was wounded in an engagement near Atlanta, Georgia, May 9th, 1834, by a musket ball, which entered just over tlie external canthus of the left eye, passed upward and backward, and lodged under the scalp, near the occipital protubei-ance, fracturing the skull in its whole course. He was admitted to the Institute Hospital, Atlanta, Georgia, on May 11th, being completely unconscious and imable to move his limbs; pulse feeble aud £0, deglutition almost impossible, and the j)ower of articulation almost entirely lost. There was grea tumefaction and discoloration of the whole face and head. A sci’uple of calomel was with difficulty administered, which, on thet following day, produced free purgation. On May 12th, he seemed to understand when spoken to, and on the following day could see a little out of the right eye. On the 16th, brain substance was sloughing out from the anterior wound. On the 19th, wounds discharged cerebral matter freely, and a soft tumor appeared near the posterior wound. Involuntary actions of the bowels occun-ed, the pulse became slow and feeble, aud the patient was thought to he sinking. On the' 16th, the abscess near the jiosterior wound opened and discharged freely. From that date his condition improved. On .lime 1st, ho was partially conscious, and could articulate a feiv words. There was now w’ell-nuu'ked hemiplegia of the right side. Several loose splculae of bone were removed. A gradual and steady improvement took place. On June 30th, his appetite-was good; he could sit up in bed, and was rapidly gahuug strength, but articulated imjierfectlyv The tumefaction had subsided, and revealed depressed bone to the extent of si.x iiiclics in length by four in width. The wounds were open aud siqqmratiug. The case is reported by Surgeon 1). C. O'Keefe, 1’. A. C. S. CASI't. — Rl'ivate L. IS. Locegreen, Co. A, 25th South Carolina Regiuient, was wounded in an engagement at Walthal Junction, Virginia, May 7th, 1834, by a conoidal ball, which struck the iqiper and receding portion of the frontal bone, left side, one inch from the median line; the outer table was fractured, the edges being roughened aud irregular ; the inner talde was broken into several fragments varying in size. The wound was an inch wide and nearly an inch and a half in length, extending almost to the coronal suture. He was senseless for over an hour, but then recovered eonsciousness. The loose spiculffi were removed, simple dressings applied, and on the following day he was .sent to Richmond. Pieces of bone were I’emoved as they became sejiarated. He was delirious more or less for three weeks ; the wound looking unhealthy, with a tendency to sloughing. Poultices and disinfecting lotions were substituti'd for sinqdc dressings. At the end of the fourth week, the case looked more favorable, and shortly afterward the patient was returned to iSoutli Candina, the wound being still oiieu and spiculffi of bone discharging from time to time; thirty-seven spieuhe eauie away in all. In July, 180.5, a linn cicatrix had formed over the cavity. In March, 1806, the man was not equal to niueh jihysical exertion; he sjioke slowly and with less fluency than before and suffered eontiuually from hemicrariia, most severe at the site of the wound and invariably brought on by bodily and mental exertion or exposure to the sun. Cannot indulge in stimulants. The case is leported by iSurgeon F. S. Parker, P. A. C. S. 246 WOUNDS AND INJUEIES OF THE HEAD Case. — Private John McG , Co. C, 1st Maryland Eegiment, aged 27 years, was wounded at the battle of Gettys- burg, Pennsylvania, July Jd, 18C3, by a conoidal musket ball, wliicli fiaetnrcd both tables of the left parietal bone. He was admitted into Seminary Hospital, Gettysburg, and thence transfeired to Baltimore, and admitted into West’s Buildings Hospital on the 28th. Partial hemiplegia of the right side existed, aflecting both limbs to some extent. Simple dressings were applied and stimulants administered. On August 3d, Assistant Surgeon E. Brook.s, U. S. A., removed fragments of bone to the extent of one and a half by three-fourths of an inch in surface, -which had become detached. This greatly relieved the hemiplegia. By the 10th, the patient was able to walk about the ward and appeared to sutler no inconvenience excejit a little uncertainty and weakness in his gait. On August 31st, the wound was fast closing and discharging but very little. The patient ate and slept well and acted as nurse for some time. On November 12th, he was transferred for exchange; and, on the 16th, admitted into the Chimborazo Hospital, Eichmond, Virginia. He had entirely recovered. The pathological specimen is No. 1719, Sect. I, A. kl. M., and shows live necrosed fragments from the left parietal bone, removed by operation. The specimen and history wcfl-e contributed by the operator. Assistant Surgeon E. Brooks, U. S. A. Fhilips, T. M., Private, Co. I, 11th Alabama Eegiment. Gettysburg, July 2d, 1863. Gunshot fracture of left parietal bone near vertex. Chester and Point Lookout hospitals. Eemoval of several fragments of bone. Exchanged March 3d, 1864. Stiegel, Charles B., Co. II, 5th Virginia Eegiment. Fort Steadman, March 25tli, 1865. Fracture of right parietal by conoidal ball. Corps and Washington hospitals. Eemoval of fragments of depressed bones. Eecovered, and released on taking the oath of allegiance. Pcllum, E., Private, of Holcomb’s Legion. Near Charlottesville, September, 1862. Gunshot fracture of frontal bone. Treated at Charlottesville. Eemoval of loose fragments of bone, including portions of the orbital plate. Furloughed October 8th, 1862. Toleman, William, Private, Co. L, 55th Virginia Eegiment. kVilderness, May 6th, 1864. Gunshot fracture of external angular process of frontal bone. Field and Chimborazo Hospital. Eemoval of several pieces of bone. Furloughed June 23d, 1864. Dixon, H., Private, Co. D, 30th North Carolina Eegiment. Gunshot fracture, with depression of both tables of left parietal bone. Chimborazo Hospital. Eemoval of loose pieces of bone. F urloughed August 25th, 1832. (JEourlce, Captain, 5th Louisiana, klaryland Heights, Jnly 6th, 1864. Gunshot ii-acture of frontal bone by conoidal ball. Considerable brain matter escaped. Loss of consciousness, and convulsive movement of right side. Depressed bone elevated, and fragments removed. Eesult unknown. Cooh, M. S., Private, Co. C, 48th North Carolina, aged 23 j-ears. Petersburg, September 16th, 1864. Fracture of righ temporal by a conoidal b.alh Eemoval of fragments. Farmville Hospital. Eesult unknown. Sharp, Gordon, Private, Co. G, 6th Alabama. Gunshot fracture of cranium. Petersburg, April 2,1835. Corps and City Point hospitals. Eemoval of spiculm. Eecovered. Willingham, S. M., Private, Co. D, 5th Alabama, aged 25 years. Gunshot fracture of frontal bone, right side. Boonsboro’, Maryland, September 14tli, 1862. Philadelphia and Charlottesville hosjdtals. Eemoval of fractured bone. Eccovery. Cogan, Tobias, Private, Co. B, 19th Virginia Cavalry. kVinchester, Virginia, August 20th, 1834. Gunshot fracture of frontal bone by conoidal ball. kVinchester and Baltimore hospitals. Eemoval of fragments of bone. Exchanged. Damron, I. T., Private, Co. H, 18th South Carolina Eegiment. Gunshot fracture of frontal bone. Charlottesville hospital. September 6th, 1862. Eemoval of several pieces of bone. Fuiloughed October 8th, 1862. In three cases of removal of fragments from the cranium, it has been impracticable to trace the histories to a conclusion. They probably kvere all three examples of recovery : kViLSON, T., Private, Co. D, 5th United States Cavalry, aged 28 years, was wounded at Brandy Station, Virginia, June 9th, 1863, l)y a musket ball, which fractured the left parietal protuberance, about four inches above the car. He was insensible for several days, and partially paralyzed on the right side. He was taken prisoner, and conveyed to Confederate hospit.al at Charlottesville, Virginia, where, on June 13th, the ball and pieces of bone were removed. On July Cth he was apparently doing well, and the wound healing. He never complained of pain in the head, but had a constant numbness and pain in his i-ight arm, with partial loss of its motions. But this -^vas rapidly improving, and ho bade fair to recover entirely. The case, is reported by Assistant Surgeon B. kV. Allen, P. A. C. S. Case. — Corj>oral Theodore Boese, Co. K, 1st New Jersey Volunteers, was, on August 13th, 1863, admitted to Ladies’ Home Hospital, New York, with a wound of the head. On examination, the bone was found to be depressed. Several spiculae were removed, when all bad symptoms disappeared ; but his memory remained impaired, and at times he would experience severe pains in the region of the wound. He deserted November 1st, 1833. Case. — Frederick E , 43d Illinois Volunteers, received, at the battle of Shiloh, April 6th, 1832, a gunshot fracture of the parietal bone, near its posterior superior angle. The loose pieces of bone were carefully removed, the ilaps adjusted, wr.rm water dressings aj)plied, and opiates freely administered. In about three weeks a cartilaginous substance cijinmcnced to be deposited in the space from which the fragments had been removed. This substance became to some extent ossified, and in about six weeks the wound had entirely healed. The case is reported by Assistant Surgeon S. B. Houts, 18th klissouri Volunteers. TvEMOVAL OF FEAGMENTS AFTEE GUNSHOT FEACTUEES OF THE SKULL. 247 Fatal Cases of Gunshot Fractures of the Shull treated by the Fcrtwval or Elevation of Fragments. — Tlie following series of fatal cases of gnnsLot injuries of the skull treated by operation, but not by formal trephining, comprise, perhaps, more instructive instances than the series of cases of recovery, inasmuch as the extent of the injury could be ascertained with precision, and the organic alterations ensuing accurately observed. Extravasation of blood within the cranium was the cause of the rapidly fatal termination of several of these cases : Case. — Sergeant D. A. K , Co. D, 25th South Carolina Eegiment, was ■wounclecl at Six Mile House, Virginia, August 21st, 1864, by a conoidal ball, which causer! a depressed fracture of the frontal bone. He also received flesh wounds of the right aiTn, left fore-ann and hip. Soon after the reception of the wound, he was sent to the hospital of the 3d division. Fifth Corps, where eight fragments of bone were removed from the vault of the cranium, on the day of his admission, by Surgeon E. G. Chase, 104th New York Volunteers. But the symptoms of compression were not I’clieved, and the patient gradually sank into a comatose state and died August 23d, 18G4, from cfi'usion of blood over the brain. Six of the I’emoved fragments are represented in the adjacent wood-cut, and were contributed, with the history of the case, by the operator. Fig, llfi. — Fragments of skull removed for depression from p’unshot fracture cf the right parietal. Spec. 4744, Sect. J, A. ]\I. M. Case. — A soldier, supposed to be John R , Co. D, 0th Massachusetts Volunteers, aged 22 years, was admitted into the Stanton Llospital, Washington, on M.ay 18th, 1834, having been wounded five or six days previously by a conoidal ball, wliich entered the left side cf the frontal bone, three-quarters of an inch above the frontal protuberance, and lodged in the brain. He was in a comatose condition ; his respirations were sighing, pulse 110 and feeble, pupils dilated, and his right side was jiaral vzed. ' Assistant Surgeon George A. Mursick, U. S. V., enlarged the wound of soft parts by crucial incision, and removed four s])linters of bone with an elevatoi’, one of them being depressed about half an inch. An ice bag- was applied to tiic b.ead and a stimulating enema ordered, but the patient sank rapidly and died May 19th, 18G4, ton hours after the operation, from extravasation of blood. The autopsy showed the anterior lobe of the left cerebrum to be injured. There was a copious exudation of plastic matter between the dura mater and the arachnoid. The specimen is No. 2381, Sect. I, A. M. M., and was contributed, with the history, by Assistant Surgeon George A. Mursick, U. S. V. Case. — P rivate William B , Co. G, 8th Pennsylvania Cavalry, aged 18 years, was wounded in an engagement at Deep Bottom, Virginia, August 14th, 1834, by a conoidal ball, which fractured and depressed the posterior portion of both tables of the right parietal bone. The ball, which was split from apex to centre, was found impacted on the edge of the fracture and was removed on the field. He was admitted, on the following day, to the hospital of the 2d division. Cavalry Corps, and thence conveyed to 'Washington, where he entered the Emory Hospital, August 17th. Cold water dressings were applied, the head kept cool by constant application of iced water, and low diet ordered. On the morning of the 20th, there wero symptoms of compression ; jmlse 88, slow and soft. Chloroform was administered and Surgeon N. R. Moseley, U. S. V., removed five small fragments of bone which had become detached, and elevated the depressed bone. The soft parts were quite extensively lacerated. A strictly antiphlogistic course of treatment was established, and the patient remained comfortable until the evening of the 23d, when febrile symptoms of a severe character occurred; death supervened on August 25th, 1834. An autopsy showed extensive disorganization of the brain; the middle lobe cf right hemisphere was in a suppurating condition, and the diseased action had extended as far back as the base of the brain. The pathological specimen is shown in the wood-cut, and was contributed by the operator. Surgeon N. R. Moseley, U. S. V. Case. — Corporal Henry F. M , Co. G, 39th Massachusetts Volunteers, aged 19 years, was wounded at the battle of Spottsylvania Court-house, Virginia, May 12th, 1834, by a conoidal musket ball, which penetrated the right frontal and parietal bones and lodged in the brain. He was admitted to the 3d division. Second Corps, hospital, and on the 18tli, transferred to the Stanton Hospital, Washington. His intellect was confused, but he would answer questions intelligently when spoken to in a loud voice. His left side was paralyzed; respiration sighing; pulse 120 and full. He complained of intense jiain in his head, and had purulent conjunctivitis of both eyes, with rupture of the cornea of the left eye. Deglutition was unimpaired. On Slay 19th, Assistant Surgeon George A. Mursick, U. S. V., enlarged the wound by crucial incision, and removed tb.o depressed bone with an elevator. Ice was applied to the head, a stimulating enema, fluid extract of acoiute, and an astringent lotion for the eyes, ordered On the 20th, coma supervened and deglutition became difiicult. On the22d, his breathing was stei foroue-, with puffing of the corners of the mouth. The comatose condition continued without interruption until the day of his death. May 2^>th, 1834. At the autopsy, the ball was found lodged in an ab-scess in the posterior lobe of the right hemisphere. I’urulent de|)osit between the dura mater and the arachnoid extended over the whole hemisphere. The pathological specimen is No. 2380, Sect. I, Eig. 117. — .Split ball and fragments f f rigl.t liarictal. Spec. 3131, .Sect. I, A. M. Ivl. \. 248 WOUNDS AND INJURIES OF THE HEAD, A. JI. M. A segment of cranium fractured at tlic coronal suture. Five fragments of bone, chiefly from the inner table, are attached. Ths opening externally measures one-half by one inch, the edge being beveled internally. The specimen and history tvere contributed by Assistant Surgeon G. A. IMursick, U. S. V. Case. — Private T. AI. J , Co. II, 45th North Carolina Regiment, aged 38 years, was wounded at Silver Spring, near Washington, Jidy l'2th, 1834, by a colloidal ball, which entered at the middle of the superior border of the right temporal bone, and passing transversely, fractured both tables of the skull. He was taken jirisoner and conveyed to the Lincoln Hospital, Washington, on the 17th, being conscious at the time. On the 27th, the wound was enlarged and fragments of bone were removed. The wound was in a healthy condition, and the patient's pulse full and regular. Convulsions, followed by paralysis of the right side, succeeded the operation. These symptoms continued until the 29tli, when be became comatose. Mercurial jnirgatives, cold applications, friction and sinapisms to the extremities, were used without avail. The patient sank rapidl}", and died on the 29th. 'Yhn post-mortem examination revealed a fragment of bone, about one inch in diameter, lying upon the brain substance. An abscess existed about the size of an English walnut. The brain substance of the riglit lobe was much softened and congested, and the ventricles were filled with serous fluid. The vault of the cranium was preserved, and is figured in the wood-cut. Fragments have been removed from ati elliptical space, measuring one by one and one-fourth inches. The posterior half of the sagittal suture is separated, and five fissures radiate from the fractured point. The edges of the opening are necrosed, cribriform, and crumblii^. The specimen and history were contributed by Acting Assistant Surgeon T. L. Leavitt. Case. — Sergeant Joseph C , Co. B, 3d Pennsylvania Cavalry, was wounded at the battle of Mine Run, Virginia, November 27th, 1833, by a conoidal musket ball, which entered above the right zj’goma and penetrated the skull. lie was treated in the field hospital until December 4th, when he was conveyed to Alexandria and admitted to the 3d division hospital. Delirium had supervened, which continued until within twelve hours of his death. Several fragments of bone were removed, but the patient was unable to take food, and drank but two or three times of whiskey and water. He became comatose, and died on December 5th, 1863. At the autopsy, the right lobe of the cerebrum was found to be comjtletely destroyed. The pathological specimen is No. 2641, Sect. I, A. M. M. The perforation is at the centre of the squamous suture, and measures three-fourths of an inch by one inch externally, having the edges beveled at the expense of the inner table. There is no Assuring. The specimen and history were contributed by Surgeon E. Bentley, U. S. V. Case. — Private Foster H. B , Co. E, 7tli Michigan Volunteers, aged 20 years, was woiuided at Re.am’s Station, A'^irginia, August 25th, 1864, by a conoidal ball, which fractured and depressed the frontal bone over the left orbit, tearing off a portion of the external table tw'o and a quarter indies in length, and nearly an inch in width. In the same engagement he received a flesh wound of thigh. He w'as taken to the 2d division. Second Corps, hospital, where a portion of both tables was removed by Surgeon G. Chaddock, 7th Michigan Volunteers. On the 28th, he was conveyed to AVashington, and admitted to the Lincoln Hospital. Two days later he became delirious. Coma supervened on September 1st, and the pupils contracted. On the 3d, while the coma still existed. Acting Assistant Sui-geon T. F. Betton made an elliptical incision through the integuments, and remov'ed a portion of a musket ball and several depressed fragments of bone from the anterior lobe of the brain. The wound was cleansed, and the edges brought together and united by straps of adhesive plaster. The operation failed to relieve the coma, and patient died the same day. The post-mortem examination revealed a portion of the inner table, about the size of a dime, depressed; the meninges of the brain were batbed in pus, and a large abscess existed in the anterior portion of the left hemisphere, the substance of the brain surrounding it being very much softened. The pathological specimen is No. 2078, Sect. I, A. M. Al., and was contributed, with tlie history, by Acting Assistant Surgeon H. M. Dean. Case. — Sergeant Presley AV. N , Co. C, 1st Ohio Volunteer Cavalry, aged 24 years, was wounded near Culpeper, A'’irginia, September 13th, 1833, by a musket ball, which cojnminuted both tables of the left temporal bone two inches above the mastoid process. He was conveyed to AVashington, and admitted into Armory Square IIos[)ital on the 15th, where simple dressings tvere applied to the wound. The head symptoms were very slight until October 7th; from that time he gradually grew worse. On the 17tli, nau.sea and vomiting supervened. An incision was made over the cicatrix by Surgeon D. AV. Bliss, U. S. V., and several small .spiculm of bone were removed, wliich, however, afi'orded no relief, and the vomiting, with increased pain in head, continued. The patient sank rapidly, and died on the 20th. The post-mortem examin.ation revealed the vessels of tlie membranes and of the brain in a high state of congestion. An abscess was found in the left ventricle, which communicated with the external wound, and contained an ounce of dark. Fig. Its.— Sef’-mpnt of left temporal bone, greenish pus. The substance of the brain in the vicinity of the abscess was softened, from which fragments have been removed. Communication existed between the external wound and the abscess, which was size.] hlled with spiculffi. Ibe pathological specimen is represented m the adjacent wood- cut. The edges of the fracture in the cranium are somewhat I'oundcd, exhibiting evidence of attempts at repair. The specimen and history were contributed by Surgeon D. W. Bliss, U. S. V. Case. — Private Otis G , Co. C, 16th Maine A'’olunteers, aged 21 years, who was a very stout and vigorous person, weighing 180 pounds, was struck, at the affair on the AV'eldon Railroad, August 18th, 1834, upon the top of the head by a conoidal musket ball, which produced a fracture of the skull one inch posterior to the coronal suture. On the following day ho was admitted into the field hospital of the 3d division. Fifth Corps, where he remained until the 21st, when ho was conveyed to AA'ashiugton, and admitted into the Lincoln Hospital. Ice-water dressings were aiiplied to tho head, and sedatives were administered. In the progress of the case, fragments of both the outer and inner tables were removed, leavhig the brain exposed. EEMOVAL OP FEAGMENTS AFTEE GUNSHOT FEACTUEES OF THE SKULL. 249 The patient failed rapidly, and died apparently from exhant-tion on August 30th, 1.8G3. At tlie autopsy, the scalp in the. vicinity of the wound was found to he infiltrated with pus, the periosteum being easily detached. The fracture involved both jiarietal bones, measuring one-half by one inch, the longest diameter rumnng at right angles with the sagittal suture. Upon the removal of the calvarium, the depressed portion of hone was held in position by the dura mater. Through both tables of the left parietal bone, from the jilace of injury to the posterior inferior angle, ran ii fissure, along which tnices of an attemi)t tit repair were observed. The meninges in the vicinity were congested and thickened. In the left hemisphere a cerebral abscess existed, extending from the surface of the brain to a level with the cor[)iis callosum, three-fourths of an inch in diameter. The contiguous portion of brain was much softened, as was the right hemisphere within the limits of the fracture. The pathological specimen is No. 3150, Sect. I, A. M. JL, and was contributed by Acting Assistant Surgeon H. M. Dean. Case. — Corporal AYilliam M , Co. E, 23d Pennsylvania Volunteers, was wounded at the battle of Malvern Hill, Virginia, July 1st, 1862, by a fragment of shell, which fractured and depressed the right parietal bone, about one inch from the sagittal suture. He was conveyed to New York, and on the 24th admitted into the DeCamp Hospital, David’s Island, New York harbor. Hemiplegia of the right side of the body existed from the date of the injury ; but with this exception no unfavorable symptoms appeared until August 15th. On the following day two pieces of necrosed bone, about an inch and a half in diameter, and also portions of depressed bone, were removed with the forceps. A very fetid pus surrounded the fractured parts. The patient was delirious, grew rapidly worse, and died August 17th, 1862. The autopsy revealed au abscess about two inches in extent, seated in the left henusphere of the brain, immediately below the seat of the injury. The pathological specimen is No. 1059, Sect I, A. M. M., and consists of a portion of the cerebrum, with a small abscess in the upjter part of the anterior lobe of the right hemisphere. On the external surface of the brain, one-half inch to the right of the longitudinal fissure, is a dark spot, with disorganization of the brain substance, and the surrounding parts are discolored. The case is reported by Sin-geon S. W. Gross, U. S. V. Case. — Private James F. W , Co. H, 3d Maine Volunteers, aged 24 years, was wounded at Eaccoon Ford, Virginia, November 27th, 1863, by a musket ball, which fractured both tables of the occijjital bone, just above and to the left of the protuberance. He was admitted to the 1st division. Third Corps, field hospital on the same day, and transferred to the 3d Division Hospital, Alexandria, Virginia, on December 4th. On the following day he was still conscious, but very restless; his head was very painful, pulse 120, strong and full, tongue coated and dry, skin hot and bowels constipated. During the night he was delirious and vomited often, and on the next morning he became comatose. A piece of bone, one inch long, and three-fourths of an inch wide, was removed from the wound, but failed to relieve the patient, and he died at twenty minutes after three o’clock P. M. of the same day. The autopsy revealed a congested and discolored state of the meninges, and an abscess extending from the wound into the left lateral ventricle. Several small spiculm were lying loose in the wound. An opening was found near the middle and a little to th(»»Ieft of the centre of the occipital bone, through which a portion of the brain was protruding. The pathological specimen is Eo. 1904, Sect. I, A. M. M., the posterior portion of the cranium showing a nearly circular fracture of both tables. The internal surface of the opening, which measures one inch in diameter, is slightly the larger. The specimen and history were contributed by Acting Assistant Surgeon J. Cass. Ca.se. — Private Peter W , jr., Co. F, 126th New Yorlc Volunteers, aged 19 years, was wounded at Bristow Station, Virginia, October 14th, 1883, by a conoidal musket ball, which fractured and depressed the inferior angle of the left parietal, at its junction with the frontal bone, and penetrated the brain. He was admitted into the 2d division hospital, Alexandria, on the 15th, in a state of insensibility. His right side was paralyzed, pulse 56 and full, and the pupils were somewhat contracted. On the 16th seven pieces of bone were removed ; the largest being nearly an inch square. A large quantity of sanguinolent fiuid was discharged, in which appeared portions of brain matter. The next morning a discharge of a bloody, foul-smelling fluid followed, and the patient passed his urine involuntarily. On the IStli the discharge continued; the pulse became more frequent and feeble, and death occuiTed at two o'clock A. m., October 19th, 1883. The post-mortem revealed inflammation of the membranes over both hemispheres; also an abscess occupying the upper half of left hemisphere of the cerehrum, at the posterior pai't of which was found a rifle ball. The pathological specimen is No. 1739, Sect. 1, A. M. M. The de])rossed iiortion measures one by one and a half inches, from which four fragments have been removed. A fissure extends diagonally across the parietal bone, from the anterior inferior to the opposite angle, and another fissure passes downward. The specimen and history are contributed by Acting Assistant Surgeon C. 1‘. Bigelow. Case. — Private Warren W , Co. A, 159th New Yoi-k Volunteers, aged 26 years, was wounded in the action at Irish Bend, Louisiana, April 14th, 1833, by a conoidal musket ball, which cut the .scalp upon the right side of the head, one inch and a half in extent, so that the belief was entertained that the wound had heen produced by a li-airmeut of shell. Violent delirium succeeded rapidly, as reported by the field surgeon who had charge of the case i)revious to his admission into the University Hospital at New Orleans, April 17th, 1883. An examination of the wound was now made with a probe, which j)enetrated the brain by its own weight to the distance of four inches. On tht; following day he was restless, moaned, and complained of pain in the head, and toward evening active delirium supervened, which subsequently alternated with periods of quiet consciousness. Spasms, however, occurred at all times. On the eleventh day after the injury a fraginentof bone was discharged from the wound, after which he seemed quite rational. But delirium soon returned, followed by coma, and death resulted on the morning of April 27th, 1883. At the autopsy, the space from which fragments of bone had been removed, at the ])osterior inferior angle of the parietal bone, measured one and one-fourth inches in length by three-fourths of an inch in width, the edges of the opening being beveled at the expense of the inner table; a fissure through both tables passed forward to the squamous suture. One fragment of the inner table was depressed two lines, but remained attached. The inner table in the vicinity of the fracture, exhibiti^d evidences of extensive disease. The cerebral substance immediately surrounding the missile, which was flattened and battered, was disorganized ; otherwise the brain ap|)eared healthy. The j)ia mater ai)py shell. Chimborazo Hospital, Richmond. Removal of fragments of bone. I laemorrbage. Death, .June 8th, 1834. 256 WOUNDS AND INJURIES OF THE HEAD, Neal, Joseph, Private, Co. B, 1st Jlaryland. Chaiicellorsville, May 3cl, 1863. Fracture of right parietal bj' canister- shot. St. Aloysius Hospital, Washington. May lOtli, removal of spicnla;. June 8tli, hemorrliagc from a branch of the temporal artery. Died June ICth, 1863. Taylor, Rodxey I., Private, Co. F, Ist Maine Heavy Artillery, aged years. Spottsylvania, May 19th, 1864. Fracture of left temporal by conoidal ball. Armory Square Hospital, Washington. Removal of spicula;, and ligation of temi^oral arteiy, June 3d. Death, June 5th, 1864. In four instances, the bleeding was from vessels within the skull ; in two, from the temporal artery or its branches ; in one, from the jugular vein. In two of the cases of intracranial bleeding, solutions of persulphate of iron on dossils of lint were employed. In the case of rupture of the middle meningeal artery. Surgeon E. Bentley, U. S. V., resorted to the extreme measure pf ligating the common carotid artery. The hsemorrhage did not recur; but the patient succumbed on the thirteenth day, after a series of chills and other phenomena of pysemic infection. In the case of Aberneathy,^ paraplegic, treated by Dr. J. S. Davis, of the University of Virginia, the temperature was observed, and found lowered on the side opposite the injury. In three of the seven cases, balls, as well as bone splinters, were removed. Surgeon N. R. Moseley, U. S. V., ascribed the almost instantaneous death, in the patient with hsemorrhage from the jugular vein, to the entrance of air into the vessel, which was found largely opened by ulceration. Gangrene . — Among the cases of this category were three of sloughing of the wound of the scalp : Caley, John, Sergeant, Co. A, 11th Tennessee Cavaliy, aged 51 years. Nashville, October 27th, 1864. Penetrating fracture of parietal by pistol ball, during an affray. Cumberland Hospital. Removal of fragments. November 5th, gangrene aj^peared. Death, November 7th, 1864. Shannon, James F., Captain, Co. C, 9th Pennsylvania Reserves, aged 33 years. Bull Run, August 29th, 1862. Gunshot fracture of left parietal. Hospital at Georgetown, D. C. September 7th, removal of fragments of bone; September 10th, gangrene ; September 12th, death. Starr, James A., Corporal, Co. B, 18th Indiana. Gunshot fracture of the left parietal. Admitted to Hospital No. 6, New Albany, Indiana, October 7th, 1863. Removal of fragment of bone. December 20th, gangrene attacked the woimd. Death, December 26th, 1863. Pyaemia . — This complication is not often referred to in the notes of the cases of this class, though doubtless often existing unremarked. The all-pervading malarial element to which our sick and wounded were continuously exposed, while modifying the symptoms of many diseases, served yet more remarkably to mask the phenomena resulting from traumatic affections. And this was especially true in regard to pyaemia. The most skilled observers were frequently at a loss, whether to regard a chill occurring in a wounded man, as the result of the malaria of the locality, or the premonition of pus formation. In a great number of cases time or opportunity for autopsy were lacking. Bristol, L. T., Corporal, Co. G, 37th Wisconsin, aged 25 years. Petersburg, July 30th, 1864. Fracture and depression of occipital by conoidal ball. Field and New York hospitals. Removal of fragments of bone. August 11th, pyaemia developed. Died August 14th, 1864. ChrisJiolm, Neal Jf., Private, Co. H, 17th Alabama Regiment, aged 38 years. Atlanta, July 20th, 1864. Fracture of frontal by conoidal ball. Nashville hospitals. Removal of fragments of bone, September 5th. October 6th, pyaemia supervened, resulting in death, October 12th, 1864. Abscess . — Formations of pus between the skull and membranes, and within the brain tissue, were not uncommon. Archel, Moses, Private, 22d U. S. Colored Troops, aged 28 years. Petersburg, June 15th, 1864. Fracture of frontal l>y conoidal ball. Field and Balfour hospitals. Removal of fragments at various times. Died August 11th, 1864, from pressure on brain produced by pus accumulated beneath the skull. * For a full account of this case, see Confederate States Medical and Surgical Journal. Vol. I, page 42. Mareh, 1864. EEMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 257 Haydon, Michael, Private, Co. D, Cth Wisconsin. Gettysburg, July 1st, 18G3. Fracture of loft side of frontal bone by colloidal ball. Camp Letterman and York hospitals. Removal of fragments. Epileptic convulsions July25lli. Death, August 5th, 1863. Autopsy revealed a large abscess under pia mater. Parker, Louis, Private, Co. K, 43d New York, aged 32 years. Fredericksburg, December 13th, 1862. Fracture of occipital by conoidal ball. Third division hospital, Alexandria. Removal of several fragments. Died January 13th, 1863. Autopsy revealed two ounces of grayish pus between dura mater and cerebellum. P , Dominick, Private, Co. K, 10th New York. Fredericksburg, December 13th, 1862. Depressed fracture of occipital by conoidal ball. Field and Georgetown hospitals. Several fragments of bone removed. Death, December 31st, 1862. Autopsy revealed subarachnoid effusion of blood and softening of posterior lobe of brain. Viscera inflamed. The pathological specimen is No. 865, Sect. I, A. M. M., a segment of cranium, with depression of fragments. Contributed by Brigade Surgeon John L. Le Conte, U. S. V. _ Turney, Richard L., Private, Co. E, 2d Pennsylvania, aged 23 years. Petersburg, August 3d, 1864. Fracture and depression of right parietal by shell. Field and Fort Monroe hospitals. Removal of pieces of depressed bone August 9th. Died August 10th, 1864, from compression of the brain by pus beneath the dura mater. Dunham, George W., Private, Co. E, 9th New York Heavy Artillery. Cold Harbor, June 1st, 1864. Penetrating fracture of left parietal by conoidal ball. Corps and Fairfax Seminary hospitals. Removal of fragments. Died June 11th, 1864, from abscess formed in the brain. Unknown. Gunshot fracture of left temporal. Lincoln Hospital, Washington, April 8th, 1865. Removal of fragments April 10th. Died April 12th, 1865. Autopsy showed a large abscess involving nearly the entire left side of cerebrum. Worley, William, Private, Danville Artillery, aged 22 years. Petersburg, April 1st, 1865. Penetrating fracture of parietal by conoidal baU. Lincoln Hospital, Washington. Removal of fragments April 18th. Death, April 23d, 1865. Autopsy revealed an abscess in upper portion of brain. Encephalitis . — Of course nearly all the fatal cases might come under this heading, but a few, undistinguished by special complications, are placed here : Quine, John, Private, Co. G, 12th Illinois. Allatoona, Georgia, October 5th, 1864. Fracture of fi-ontal, left side, by conoidal ball. Left eye destroyed. Corps hospital. Removal of fragments and some brain substance. Meningitis. Died October 13th, 1864. Smith, John E., Private, Co. D, 16th Indiana. Arkansas Post, January 11th, 1863. Fracture of left parietal by grape-shot. Dura mater not injured. Adams Hospital, Memphis. Removal of depressed bone. Inflammation of meninges. Died February 8th, 1863. Howeth, John, Lieutenant, Co. C, 6th New Jersey. Chancellorsville, M.ay 3d, 1863. Fracture of fi-ontal by conoidal ball. Removal of ball and fragments. Aloysius Hospital, Washington, May 13tli. Traumatic encephalitis. Died May 14th, 1863. Louderbeck, George, Private, Co. B, 4th Ohio, aged 27 years. Ream’s Station, August 25th, 1864. Depressed fracture of frontal bone by conoidal ball. Corps and Emory hospitals. Elevation and removal of spicula) August 31st. Died September 3d, 1864, of phreuitis. Taylor, J., Private, Co. C, 5th North Carolina Regiment, aged 23 years. Winchester, September 19th, 1864. Fracture of cranium by conoidal ball. Depot hospital at Winchester. Removal of fragments. Died September 21st, 1864, from cerebritis. Thompson, William, Private, Co. E, 10th Massachusetts, aged 41 years. Spottsylvania, May 12th, 1864. Fracture of frontal by conoidal ball. Corps and Emory hospitals. Removal of baU and fragment of bone May 18th. Inflammation of brain. Died May 30th, 1864. The two following cases illustrate the danger of cerebral inflammation at periods remote from the reception of the injury : Young, George J., Corporal, Co. D, 29th Ohio, aged 20 years. Pine Knob, Georgia, June 15th, 1864. Fracture of frontal by conoidal ball. Field, Nashville, and Columbus hospitals. Removal of fragment of bone. Inflammation of brain. Died June 13th, 1865. B , Hugh, Corporal, Co. I, 2d U. S. Infantry, aged 33 years. Gettysburg, July 2, 1863. Fracture of frontal and zygomatic process of malar bone by conoidal ball. Left eye destroyed. Gettysburg and York hospitals. Removal of several fragments. Died February 6th, 1864, from inflammation of brain, the-result of a debauch. Missiles lodged . — The nine following cases present examples of the lodgment of projectiles in the brain tissue : Atchinson, Nathan, Private, Co. F, 7th Illinois. Allatoona, October 5th, 1864. Penetrating fracture of frontal, left side, by conoidal ball; missile lodged. Field hospital. Removal of fragments; loss of brain substance. Died October 10th, 1864. 33 258 WOUNDS- AND INJUEIES OF THE HEAD, Caulhh, E. T., Private, Co. I, 3d New Hampshire. Fort Darling, May 15th, 1864. Fracture of sphenoid and petrous portion of left temporal bone by conoidal ball. Field and I’oint Lookout hospitals, lieinoval of fragments. Died May 22d, 1864. At the autopsy a portion of the missile was found driven deeply into the brain matter. Claek, Henry, Private, Co. B, 1st New Jersey, aged 23 years. Petersburg, March 31st, 1865. Fracture of right parietal by conoidal musket hall. Field and Washington hospitals. Removal of fragments. Died April 13th, 1865. The autopsy revealed the ball in the middle lobe of the brain. George, John, Corporal, Co. I, 51st Pennsylvania, aged 26 years. Petersburg, July 30th, 1864. Penetrating fracture of frontal by conoidal hall. Treated in field hospital. Fragments of hone removed ; missile remained in the wound. Died August 8th, 1864. JOURDON, W., Co. F, 1st United States Sharpshooters. Chickahominy, June 28th, 1862. Fracture of right parietal by conoidal musket ball. The greater part of the missile passed into the brain substance. Field and Annapolis hospitals. Removal of fragments. Died August 12th, 1862. Krieger, FRjVNCIS, Private, Co. II, 110th Ohio Volunteers, aged 20 years. Monocacy, July 9th, 1884. Penetrating fracture of left parietal ; missile lodged in the substance of the brain. Frederick hospital. Removal of several depressed fragments of bone. Died July 12th, 1834. UNKNOtVN, admitted to Lincoln Hospital, Washington, April 8th, 1865. Gunshot penetrating wound of left parietal ; missile lodged in the brain substance. Removal of depressed fragments of bone April 9th. Died April 10th, 1865. Williams, CiIjARLES P., Lieutenant, Co. F, 24th New York Cavalry. Sailor’s Creek, Virginia, April Gth, 1865. Penetrating fracture of cranium ; missile lodged in the brain substance. Field hospital. Removal of portion of bone. Death, April 10th, 1835. Henry, Charles, Private, Co. F, 26th Pennsylvania, aged 38 years. Mine Run, November 27th, 1863. Gunshot fracture of frontal by conoidal hall. Field and Alexandria hospitals. Removal of ball and fragments December 4th. Died December 6th, 1883. Next is a misplaced case of intracranial extravasation : Hawkins, William C., Private, Co. C, 11th Vermont, aged 18 years. Petersburg, June 24th, 1864. Gunshot wound of the occipital bone. Field and New York hospitals. Removal of portion of bone. Died July 14th, 1864, from cerebral apoplex}'.^ Deaths from inter current Diseases. — Three have been so classified; Burke, Andrew, Pi-ivate, Co. E, 47th Pennsylvania, aged 23 years. Cedar Creek, October 19th, 1864. Fracture of orbital bones, and lower third of right humerus, by conoidal halls. Field, Winchester, and Frederick hospitals. Removal of hone from cranium, December 13th, 1834. Died December 23tl, 1834, from phthisis pulmonalis., Dewel, Asa, Private, Co. 11, 109lh New Yoi-k, aged 27 years. Petersburg, July 9th, 1864. Depressed fracture of parietal by conoidal ball. Corps and New York hospitals. Removal of fragments of bone. Died August 10th, 1834, from chronic diarrhoea. W , William, M., Private, Co. 1, 19th Georgia Regiment. Fredericksburg, December 13th, 1862. Fracture of frontal and right parietal bones by a buckshot. Washington hospitals. Removal of fragments. Died March 1st, 1863, of pneumonia. The pathological specimen is No. 991, Sect. I, A. M. M. Probably a case of metastic foci. In many cases, the proximate cause of death was not distinctly stated : Arnold, Edwin, Private, Co. F, 2d Michigan. Petersburg, June 28th ,1864. Fracture of cranium by conoidal hall. Corps hospital. Removal of spiculse. Died June 29th, 1864. Bremer, Ludwig, Private, Co. C, 45th Pennsylvania, aged 45 years. Petersburg, April 2d, 1865. Fracture of right parietal by conoidal ball. Corps and Washington hospitals. Removal of fragments of depressed hone, April 8th. Death, April 12th, 1865. Burns, John, Private, Co. A, 45th New York. Gettysburg, July 2d, 1863. Fracture of cranium by conoidal ball. Regimental hospital. Removal of bone. Death, July 13th, 1863. Bolster, George, Private, Co. G, 2d New York Cavalry. Five Forks, April 1st, 1865. Fracture of cranium by piece of shell. Regimental and corps hospitals. Removal of fragments, April 3d. Death, April 17th, 1865. Bradford, P. C., Private, Co. I, 10th Texas. Atlanta, July 20th, 1864. Penetrating fracture of cranium by conoidal ball. Confederate and corps hospitals. Removal of bone. Death, December 28th, 1864. Boen, Nicholas, Private, Co. G, 110th New York. Vermillion ville, November 12th, 1863. Fracture of right parietal by fr.agment of shell. Corps hospital. Elevation and removal of bone. Death, December 12th, 1863. Brown, Herman, 1‘rivate, Co. C, 5th Wisconsin, aged 32 years. Fort Steadman, April 2d, 1865. Fracture of left parietal, posterior portion of temporal, and inferior portion of occipital, by a conoidal ball. Corps and Alexandria hospitals. Removal of portions of loft parietal. Death, April 8th, 1865. * This case should have foUo-vved that of Reed, on page 247. KEMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 259 Blanford, Josiah, Private, Co. D, 24th New York Cavalry. Petersburg, July 1st, 1864. Fracture of parietal by musket ball. Field hospital. Removal of fragments. Death, July 3d, 1864. • Call, John H., Private, Co. F, 14th New York. Petersburg, July 30th, 1864. Fracture of occipital by solid shot. Corps, City Point, and New York hospitals. Removal of spiculae, August 29th. Death, November 19th, 1864. Clark, Solomon, Private, Co. H, 25th Iowa. Dallas, May 28th, 1864. Perforating fracture of cranium by conoidal ball. Corps hospital. Removal of spiculae. Death, June 1st, 1864. Colored Cook of the 109th New York. Petersburg, July 10th, 1864. Fracture of the parietal and penetration of the cerebnim by a gunshot missile. Corps hospital. Removal of fragments of bone. Death, July 10th, 1864. Dunbar, Sajiuf,l, Private, Co. H, 102d Pennsylvania, aged 36 years. Cedar Creek, October 19th, 1864. Fracture of the left parietal by conoidal ball. Philadelphia and Baltimore hospitals. Removal of spiculm of bone one-half and three-fourths of inch. Paralysis. Died after discharge, February 22d, 1866. Duke, J., Private, Co. K, 9th Georgia. Darbytown, August 16th, 1864. Fracture of the right temporal and the frontal by a conoidal ball. Richmond hospitals. Removal of spicula3 of bone. Death, August 22d, 1864. Donway, S., Private, Co. A, Palmetto Sharpshooters. Fort Harrison, September 29th, 1864. Extensive fracture of the frontal by conoidal ball. Richmond hospital. Removal of spiculm of bone October 2d. Death, October 6th, 1864. Ewell, William D., Sergeant, Co. C, 38th Massachusetts, aged 38 years. Cedar Creek, October 19th, 1864. Com- pound comminuted fracture of cranium by conoidal ball. Corps hospital. Removal of depressed bone. Death, November 2d, 1884. Eggert, Solomon F., Private, Co I, 2d New York Rifles. Petersburg, June 20th, 1864. Gunshot fracture of cranium. Corps hospital. Removal of spiculae of bone. Death, July 1st, 1864. Eddy, Henry M., Captain, Co. D, 114th Pennsylvania. Five Forks, April 2d, 1865. Fracture of occipital. Regi- mental and City Point hospitals. Removal of loose pieces of bone on day of injury. Death, April 11th, 1865. Foster, James F., Private, Co. D, 100th Pennsylvania. Petersburg, October 2d, 1864. Fracture of right parietal by a musket ball. Corps hospital. Removal of spiculae and elevation of the depressed parts October 2d. Death, October 4th, 1864. Farrell, John W., Private, Co. E, 87th Indiana, aged 23 years. Chickamauga, September 20th, 1863. Fracture of left parietal by conoidal ball. Chattanooga hospital. Removal of loose pieces of bone October 1st. Death, October 12th, 1863. Galbraith, Hugh, Corporal, Co. G, 56th New York, aged 23 years. Honey Hill, November 30th, 1864. Fracture of left parietal by conoidal ball. Hilton Head hospital. Removal of fragments of bone December 1st. Death, December 1st, 1864. Horan, Michael, Private, Co. H, 10th Michigan, aged 39 years. Petersburg, June 10th, 1864. Fracture of left inirietal by conoidal ball. Field and Washington hospitals. Removal of loose bone fragments and elevation of bone July 2d. Death, July 7th, 1804. Hall, Myron, Private, Co. K, 8th Illinois Cavalry. Muddy Run, Virginia, November 8th, 1863. Fracture of the cr.anium by conoidal ball. Coi’ps hospital. Removal of fragments of bone. Death, November 10th, 1863. H^vnnowdell, W. H., Private, Co. E, 2d Pennsylvania Heavy Artillery. Petersburg, August 19th, 1864. Fracture of file frontal, left side, by a conoidal ball. Corps and Alexandria hospitals. Removal of spiculm. Death, August ftOth, 1864. Howard, O., Private, Co. F, 36th Massachusetts. Jackson, July 22d, 1863. Fracture of the cranium at the junction of parietal and occipital by conoidal ball. Corps, regimental, and Cincinnati hospitals. Removal of one square inch of skull July 22d. Death, September 22d, 1863. Hunt, Paul S., Private, Co. D, 57th Indiana. Dallas, May 27th, 1864. Gunshot fracture of the left parietal. Corps hospital. Removal of a piece of bone May 27th. Death, June 4th, 1864. ^ Keller, Conrad, Private, Co. M, 6th New York Cavalry. Trevillian Station, Juno 11th, 1864. Gunshot fracture of the skull. Corps hospital. Removal of fragments of bone. Died June 14th, 1864. Knightlinger, George W., Private, Co. F, 8th Michigan. Petersburg, July 26th, 1864. Fracture and depression of the cranium by a piece of shell. Corps and field hospitals. Removal of spiculm and elevation of bone J uly 26th. Death, December 13th, 1864. Land, Lewis J., Lieutenant, Co. B, 11th Hlinois, aged 28 years. Fort McAllister, December 13th, 1864. Fracture of the left parietal by conoidal ball. Corjis and Beaufort hospitals. Removal of spiculm from the brain December 27th. Death, January 4th, 1865. Lottz, Philip, Private, Co. H, 55th New York, aged 24 years. Williamsburg, May 5th, 1862. Fracture of the left parietal by musket ball. Baltimore and New York hospitals. Removal of fragments of bone May 19th. Death, May 21st, 1862. Martin, Edward, Private, Co. D, 5th Wisconsin. Petersburg, March 25th, 1865. Fracture and penetration of the cranium by a piece of shell. Corps and field hospitals. Removal of several spiculae from the left parietal bone March 25tli. Death, M.arch 27th, 1865. McGee, George F., Sergeant Major, 2d Michigan. Petersburg, April 2d, 1865. Fracture and depi-ession of cranium by a conoidal ball. Corps ho.spital. Removal of ball and spiculae of bone. Death, April 10th, 1865. 260 WOUNDS AND INJURIES OF THE HEAD, McColley, Patiuck, Private, Co. E, Gtli New Hampshire. North Anna, May 18th, 1864. Fracture of cranium by a colloidal ball. Corps hospital. Eemoval of pieces of bone. Died May 18th, 1864. McLaughlin, George, Private, Co. A, ‘20th Connecticut. Atlanta, August 20th, 1864. Gunshot fracture of squamous portion of left temporal bone. Corps hospital. Removal of fragments of bone. Died Angust 28th, 1864. Maeston, John, Private, Co. D, 14th New York Heavy Artillery. Fort Steadman, March 25th, 1865. Fracture of cranium by conoidal ball. Coi-ps hospital. Eemoval of spiculm of bone March 25th. Died March 27th, 1865. Mykick, Cromwell, Sergeant, Co. B, .4th Ehode Island. Petersburg, July 15th, 1864. Fracture of cranium by a conoidal ball. Corps hospital. Removal of pieces of bone. Death, July 20th, 1864. Mills, Fessendon M., Private, Co. C, 17th Maine. Gettysburg, July 2d, 1863. Fracture of cranium and injury of brain by a conoidal ball. Corps hospital. Eemoval of several spiculm. Death, July 2d, 1863. McNealy, James a.. Private, Co. A, 20th Maine. Fredericksburg, December 13th, 1862. Gunshot fracture of cranium. Corps hospital. Eemoval of spiculai of bone. Death, December 19th, 1862. Nortiiway, Clement L., Private, Co. A, 22d Wisconsin. Atlanta, July 23d, 1864. Gunshot fracture of frontal and penetration of the dura mater. C orps hospital. Eemoval of fragments of bone. Died August 1st, 1864. Pejibroke, Charles P., Private, Co. D, 7th Maine, aged 20 years. Wilderness, May 6th, 1864. Gunshot fracture of skull. Corps hospital. Eemoval of depressed bone. Death, May 6th, 1864. Rand, Irwin W., Sergeant, Co. H, Gth New Hampshire. Petersburg, July 30th, 1864. Gunshot penetrating wound of cranium. Corps hospital. Eemoval of pieces of both tables. Died August 2d, 1864. Olinger, Anthony', Private, Co. A, ICOth Indiana. Jonesboro’, September 1st, 1864. Fracture of right parietal. Corps hospital. Eemoval of fragments of bone. Died September 21st, 1864. Q , J., Confederate. Chancellorsville, May 3d, 1863. Fracture of parietal by conoidal ball. Richmond hospital. Eemoval of eight pieces of bone May 10th. Paralysis. Death, May 19th, 1863. Eees, Charles L., Private, Co. K, 95th Pennsylvania, aged 20 years. Spottsylvania, May 12th, 1864. Fracture of both tables of fi’ontal by shell. Corps and Washmgton hospitals. Eemoval of fragments of bone. Death, May 2Gth, 1864. Robertson, William, Private, Co. D, 7th Michigan. Winchester, September 19th, 1864. Gunshot fracture of the left parietal. Corps hospital. Removal of several spiculm and elevation of depressed bone. Death, September 23d, 1864. Russell, Henry, Private, Co. D, 3Gth Massachusetts. Petersburg, August 8th, 1864. Gunshot fracture of cranium. Corps hospital. Eemoval of spiculm of bone. Death, August 10th, 1864. Rutledge, Charles, Private, Co. B, 2d Illinois Artillery, aged 19 years. Accidentally, March 19th, 1864. Fracture of the right parietal by conoidal ball ; fragments of bone removed on the same day. Memphis hospital. Death, March 21st, 1864. Sachs, Martin, Private, Co. F, 147th Pennsylvania, aged 24 years. December 21st, 1864. Fracture of cranium by shell. Coi-ps hospital. Eemoval of fragments of bone. Death, December 22d, 1864. SiiEARD, Eli, Private, Co. K, 31st Wisconsin. Smithfield, March 19th, 1865. Gunshot fracture of the cranium, with depression. Corps hospital. Removal and elevation of the depressed pieces of bone. Death, March 26th, 1865. Smith, George, Private, Co. I, 51st New York. North Anna, May 18th, 1864. Fracture of cranium by a conoidal ball. Coips hospital. Removal of spiculm of bone. Death, May 24th, 1864. Smith, H. A. F., Private, Co. E, 12th Massachusetts, aged 25 years. Petersburg, June 18th, 1864. Fracture of cranium by a shell. Regimental and corps hospitals. Fractured pieces were elevated and removed. Death, June 25th, 1884. Spencer, Edyvin D., Private, Co. E, 50th Pennsylvania. Spottsylvania, May 9th, 1864. Gunshot fracture, with de- pression of the left parietal. Corps hospital. Protruding brain tissue and also seven pieces of bone were removed. Paralysis. Death, May 9th, 1864. Scroggins, Robert, Private, Co. D, 7th Indiana Cavalry. Colliersville, Tennessee, April 4th, 1865. Fracture of left parietal by conoidal ball. Adams Hospital, Memphis. Removal of fragments of bone. Died April 14th, 1865. Snyder, F., Private, Co. E, 110th Ohio, aged 43 years. Monocacy Junction, July 9th, 1864. Fracture of the cranium, with slight depression by conoidal ball. Frederick hospital. Eemoval of spiculm of bone. Died after discharge from service, March 7th, 1886. Taler, Calvin C., Private, Co. G, 56th North Carolina, aged 23 years. Petersburg, March 27th, 1865. IVacture of both tables of the frontal by conoidal ball. Corps and Washington hospitals. Removal of depressed fragments of bone April 11th. Death, April 16th, 1865. Thomas, William, Private, Co. G, 12th Indiana. Atlanta, August 14th, 1884. Fracture of the right parietal by conoidal ball. Eemoval of spiculm of bone. Death, August 15th, 1864. Tracey, Aaron, Private, Co. K, 31st Maine. Petersburg, June 17th, 1834. Fracture of the cranium by conoidal ball. Coi-ps hospital. Several pieces of bone wore remov’od. Died June 17th, 1864. Unknown. Monocacy Jimction, .July 9th, 1834. Fracture and depression of the cranium. Frederick hospital. Re- moved of the deiiressed IVagmeuts July 10th. Death, July 12th, 1864. TREPHINING AFTER GUNSHOT FRACTURES .OF THE SKULL. 261 Upton, George E., Lieutenant, Co. F, 6th New Hampshire. Petersburg, July 30th, 1864. Fracture of the cranium hy conoidal hall. Corps hospital. Removal of pieces of bone. Death, July 31st, 1864. Van Dockkum, Alexander, Corporal, Co. A, 19th U. S. Infantry. Shiloh, April 6th, 1862. Fracture of the left parietal. Louisville hospital. Removal of loose pieces of bone, April 18th. Death, April 20th, 1862. Watson, John, Private, Co. I, 5th New Hampshire, aged 21 years. Fort Steadman, March 25th, 1865. Fracture of frontal by a conoidal ball. Corps and Washington hospitals. Removal of several small spiculte of depressed bone and the ball. Death, May 3d, 1865. WakefhiLD, William W., Private, Co. H, 2d Delaware. Chancellorsville, May 3d, 1863. Comminuted fracture of the external and depression of the internal table of the frontal bone by a fragment of shell. Corps hospital. Removal of a portion of the external table, nearly an inch in diameter. May 7th. Death, May 13th, 1833. WAT:pEBURY, Peter L., Lieutenant, Co. A, 143d New York. Peach Tree Creek, July 20th, 1864. Gunshot fracture of the cranium, with depression. Corps hospital. Removal of depressed bone. Death, July 24th, 1864. Whitmore, George D., Private, Co. F, 37th Massachusetts, aged 25 years. Weldon Railroad, April 2, 1865. Fracture of temporal and parietal by a conoidal ball. Corps and Washington hospitals. Removal of several fi-agments of bone April 14th. Died on the same day. Wilber, E. A., Private, Co. I, 50th Pennsylvania. Petersburg, October 27th, 1864. Fracture of the left parietal. Corps hospital. Bone elevated. Died while on the way to a general hospital. In the preceding forty-five pages, three hundred and eighty-five instances of removal of fragments of the skull, after gunshot fracture, have been enumerated. One hundred and forty-five of these patients died, a mortality rate of 37.6 only. Four-fifths of the two hundred and forty patients included in the lists of recovery were disabled. Trephining after Gunshot Fractures of the Skull. — The determination of the conditions under which operative interference is likely to be of value, after gunshot injuries of the head, is of such great importance that I shall record all the facts relating to the subject that have been reported, and detail all the accounts of formal operations for trephin- ing performed during the war that I have been enabled to collect. The following cases of gunshot fracture of the skull, in which trephining was practiced, had a fatal termination : Case. — Private Curtis Brown, Co. K, 13th New Jersey Volunteers, was wounded at the battle of Antietam, Maryland, September 17th, 1862, by a buckshot, which fractured and depressed the frontal bone, right side, a little above the frontal eminence. He was admitted into hospital No. 1, Frederick, Maryland, on the 23d, and thence transferred to the Satterlee Hospital, Philadelphia, Pennsylvania, on the 27 th. The case was treated as a scalp wound until the 22d of February, when convul- sions supervened. On the following day. Acting Assistant Surgeon D. Kennedy made a crucial incision one and a half inches in length near the tenninus of the frontal sinus, applied the trephine, and removed a button of bone, and the missile, which was firmly imbedded in the diploic structure; also the loose fragments of the inner table. No anmsthetic was used. After the operation the flaps were brought into apposition with the silver sutures, a portion of the longitudinal incision being left open. Cold water dressings were applied to the head, and quiet enjoined. The patient rested well during the night of the 23d without the use of an anodyne, and on the following morning sufiered but little pain; the pupils were normal, and responded readily to light; his appetite was good, but the pulse rather small and frequent. On the morning of the 25th, he seemed to be more stupid, and the pupUs were less responsive, but the pulse was the same. The bowels being costive, an injection of warm castile soap suds and ol. ricini was administered. On the 26th, he suffered a gi’eat deal of pain in his head, and seemed indisposed to talk; the pupils failed to respond to light. The wound had no inflammatory symptoms, but was suppurating quite freely. On the following d.ay there was less pain; the wound still suppurated quite freely; the pulse was more full and regular, the tongue slightly furred, and the appetite improved. Death ensued March 3d, 1863. The autopsy revealed the aperture made by the trephine filled with granulations springing from the dura mater. A trilocular abscess occupied the upper part of the anterior lobe of the right hemisphere contiguous to the aperture in the bone, but not communicating with it, nor opening through the dura mater. It contained about two fluid ounces of pus. A portion of the inner surface of the frontal bone in the vicinity of the abscess had been removed by absorption. The medullary substance back of the abscess, from above the middle lobe of the cerebrum to a level with the corpus callosum, was softened and yellowish from the development of pus. Inflammation of the membranes extended a short distance back of the abscess, downward fi’om it, and at the side of the longitudinal fissure. The specimens were contributed by Acting Assistant Surgeon Joseph Leidy, and are numbered 1871 and 2219, Sect. I, A. M. M. The former shows the vault of the cranium, from which a disk has been removed with the trephine; two small fragments of the Inner table remain attached, slightly depressed at their free edg(!S. Caiies and exfoliation of the superficial lamella exist externally; internally, the entire surface of the frontal and the anterior half of the right parietal show traces of diseased action, with shght ossific deposit around the edges of the opening. The latter specimen, 2219, is a wet preparation of part of the cerebrum, with a small abscess. 262 WOUNDS AND INJURIES OF THE HEAD, Flo. 133. — Depressed gunshot frac- ture of the right parietal bone, Sj>ec. 435(i, Sect. I, A. M. M. Case. — Private J B , Co. D, 9tli West Virginia Volunteers, aged 18 years, was wotinded at the battle of Winchester, Virginia, July 20tli, 1804, by a musket ball, which fractured and depressed the right parietal bone, near its posterior superior angle. He was admitted into the General Hospital at Cumberland, Maryland, on July 23d. During the night of the 2Cth, the patient had two convidsions and gradually sank into a comatose condition until on the morning of the 27th, he was entirely insensible. The wound of scalp was discharging healthy pus. Surgeon J. B. Lewis, U. S. V., trephined and removed the depressed portion of bone, giving exit to about an ounce of bloody pus. A detached fragment of the inner table, one inch square, was removed. The patient did not rally from the comatose condition and died, on the 29th, from softening of the brain and extravasation of blood. Fost-mortem revealed a perforation of the skull at the angle of the lambdoidal suture in the parietal, which consists of one bone only in this instance, the sagittal suture not existing. A fragment of the inner table, three-fourths of an inch in length, was found driven into the brain. Tli,e pathological specimen is represented by the cut. The disk of bone removed by the trephine is in, situ and there are two radiating fissures. The specimen and history were contributed by the operator. Pig. 134. — Segment of frontal bone, carious about the aperture, whence fragments have been removed. Spec. 3631, Sect. I, A. M. M. Case. — Private W. M. B , Co. E, 83d Pennsylvania Volunteers, aged 20 years, was wounded at Petersburg, Virginia, June 20th, 18G4, by a conoidal ball, which fractured and depressed both tables of the frontal bone just below the fronto-pai’ietal suture and to the left of the median line. He was immediately admitted to the 1st division. Fifth Corps, hospital; on June 24th, sent to the Mount Pleasant Hospital, Washington, and thence, on the 27th, transferred to the Satterlee Hospital, Philadelphia. His pulse became slow and feeble, and on July 14th, his condition was very low. A disk of bone, one and a half inches in diameter, was removed, exposing the meninges of the brain. Pus flowed freely from the opening. The wound subsequently became gangrenous, and death ensued on July 26th, 1834. The post-mortem examination revealed an abscess in the left anterior lobe of the brain, with pus in the ventricles. The pathological specimen is figured in the wood-cut. The opening in the frontal bone is surrounded by a narrow ring of porous and diseased bone. The fractured por- tion of vitreous table measures one and a half by two inches. Two fr.agnients remain in situ depressed one line. These fragments are covered by a thin, granu- lar, mortar-like layer of calcareous matter. The specimen was contributed by Acting Assistant Surgeon G. P. Sargent. Case. — Private L C , Co. B, 2d Pennsylvania Reserves, ^vas wounded at Chantilly, Virginia, September 1st, 1862, by a round ball, which comminuted and depressed the right parietal bone, two inches below the sagittal suture. He became insensible and remained so for about fifteen minutes, when he recovered and walked about. He was admitted to the Harewood Hospital, Washington, D. C., on the 4th, having full power over his limbs and a good appetite. Gradually he began to feel depressed, then confined himself to his bed, and finally, on the 7th, was seized with paraplegia. On the evening of the 9th, he had become unconscious. A cathartic was administered, which operated freely, and the next morning the patient was fully conscious again and complained of pain in the head. At five o’clock P. M., of the following day he was unable to move, and his voice thick and inarticulate. His left side was nearly insensible, but wann, and he could protrude his tongue only partially. On examining the wound, a depression of the size of a twenty-five cent piece was found, but evidently no ball lodged in the brain. Chloroform was admininistered, and the fragments being so pressed i^to each other, that neither elevator nor forceps could remove them, the trephine was applied by Surgeon I. Moses, U. S. V., and the bone sawed nearly through, which loosened the pieces so that they were readily removed. The dura mater and surface of the brain were torn. Bleeding from a small branch of the temporal artery was easily checked, and the parts were covered with ice-cold water. Three and a half hours after the operation he had considerably improved; the severe pain which he had complained of for days previous to operation and the paraplegia were relieved. He slept soundly on the night of the 11th, but on the following morning a constant gurgling in his throat could be heard. Pus and blood were continually discharged from the wound, which looked well. He sank rapidly, became comatose on the morning of the 13th, and died in the afternoon of that day. The pathological speci- men, No. 131, Sect. I, A. M. M., shows a partially trephined segment of the right parietal bone, with five fragments, embracing one square inch. The outer table and diploe were cut through, but not removed, by the trephine applied on the sound bone at the edge of the fracture. The specimen and history were contributed by Surgeon I. Moses, U. S. V. Fig. 125. — Segment of parietiil bone with frag- ments, from a case of trephining after gunshot fiactura Spec. 131, Sect. I, A. M. M. Case. — Corporal Benjamin A. Carson, Co. E, 97th Indiana Volunteers, received, near Atlanta, Georgia, June 15th to 27th, 1864, a gunshot fracture of the skull. He was admitted to the regimental hospital. During the following night, hernia cerebri appeared, and on the next day. Surgeon J. H. Hutchinson, 15th Michigan Volunteers, applied the trephine, while the patient was under the influence of chloroform. Carson was, on June 29th, sent to General Hospital, and died on July 3d, 1864. TREPniNINQ AFTER GUNSHOT FRACTURES OF THE SKULL. 263 Cask. — Private P. H , Co. E, 9tli Pennsylvania Reserves, aged 28 years, was wounded at the battle of Fredericks- burg, Yirginia, Docomber 13tb, 1862, by a conoidal ball, wbicli fractured and depressed the posterior portion of tbe left parietal bone. He was unconscious for some time after tlic reception of the injury. On December 15tb, be was admitted into the Stan- ton Hospital, Washington, D. C. A wound of scalp was discovered through which could be felt a portion of depressed bone; tlu-ough another wound, two inches anteriorly, the patient stated that a portion of the ball had been extracted. No symptoms of brain lesion wei’e manifest, the patient being perfectly conscious and answering all questions correctly and intelligently. Ice was applied to the head, but, toward evening, convulsions ensued followed by others at intervals during the night. The next morning a semi-comatose condition supervened, continuing until the 17th, when it deepened. The power of deglutition was lost, and the tongue turned to the left side of the mouth. On the 18th, the condition being unimproved, an operation was decided upon. Accordingly the patient was etherized, and Surgeon John A. Lidell, U. S. V., applied the trephine to the anterior edge of the opening in the cranium and removed a disk of bone. The depressed portion, about an inch long and three-fourths of an inch wide, and six fragments of bone were easily detached. One of the latter had evidently perforated the dura mater, its re- moval being followed by a discharge of disorganized brain substance. After the operation, the coma lightened somewhat and power of deglutition and consciousness were restored ; the loss of speech, however, continued. The improvement was of short duration, for on the next day coma and paralysis of the right side again supervened, with convulsive twitching of the right side of face. These symptoms increased in gravity continuously, the patient becoming more and more exhausted until the 23d, when he died. At the post-mortem examination, a thick brown-colored pus, to the amount of an ounce and a half, escaped from between the dura mater and the brain. Under the seat of injury was found red softening and disorganization of the brain extending to the depth of an inch and a half. There was also considerable effusion of clear serum in the ventricles, and a sero- sanguinolent effusion at the base of the brain. The cerebrum generally, includ- ing both right and left, hemispheres, was congested, the punctifonn spots being unusually distinct. The dura mater, covering the convexity of the left hemisphere, showed marks of recent inflammatoi-y action, being injected, reddened, rough- ened, and of a brown color in the neighboihood of the fi-acture. It was also lined by a thick layer of false membrane. The specimen is figured in the wood-cut. The fractured portion of thb inner table of the cranium measures three-fourths by one inch, and is partly included in the disk removed by the trephine. The outer table is injured to a less extent. The specimen and history were contributed by Surgeon J. A. Lidell, U. S. V. Fig. 1‘26. — Segment cf left parietal, from a pa- tient trephined for depressed gunshot fracture. Spec. 534, Sect. I, A. M. M. Case. — Private W H , Co. B, 4th Michigan Volunteers, was wounded at the battle of Fredericksburg, Vir- ginia, December 13th, 1862, by a conoidal ball, which caused a gaping ragged wound an inch and a half long, antero-posteriorly over the left parietal, fracturing the bone. A probe could be passed through the opening so as to touch the dura mater. He was admitted to the hospital of the 1st division. Fifth Corps, and on December 16th, sent to Eckington Hospital, Washington, D. C. He was rational, but his mind was confused ; the pulse was 80 and normal ; the skin moderately warm ; pupils somewhat con- tracted and fixed ; some dysphagia, but no paralysis existed, and he complained of a constant tingling in his right arm and hand. On the 19th, his memory was entirely gone. The operation of trephining was decided upon ; the patient was etherized, and Acting Assistant Surgeon Henry W. Fisher elongated the original wound and made another section, forming a T shaped incis- ion. Upon turning back the flaps an extensive irregular fracture was discovered, also a small piece of bone was found driven down half its thickness below the surface. At its posterior edge a small fragment of lead was impacted. The trephine was applied and a button removed, revealing extensive comminution of the internal table toward the vertex. A tongue of bone, extending from the opening made by the trephine to a radiating fracture was removed by a Hey’s saw, and two irregular fi’ag- ments of the inner table, besides numerous small spicu- ItB, w-ere removed. The dura mater was discolored but not lacerated save by a small puncture made by one of the spiculsB. All extraneous substances having been removed, the wound was closed and cold water dress- ings were applied. On December 20th, the patient was semi-comatose, but quite rational when spoken to. The next morning the pupils became contracted, the coma deepened, and all the symptoms of compression of the brain appeared. Thinking that there might be a clot under the dura mater. Dr. Fisher made a small crucial incision in the membrane, but no clot was found. The wound of the scalp and the dura mater were covered with an ash-colored, semi-fluid, sloughy matter ; but on cleaning the dura mater it was found not to be slough- Fio. 127. — Calvaria and fragments from a case of trephining after gnnsliot ing, but roughened and livid. No improvement took Sect. I, A. M. M. place and the patient gradually sank until three o’clock r. M., December 2l8t, when he died. On removing the calva- rium, the membranes were found congested, but without change of texture, save the roughening and discoloration before noted, immediately about the wound. On removing themembrane, the surface of the cerebnim was found to bo in a disorganized pulpy condition for a space of an inch and a half. The convolutions were obliterated, the white and gray portions being undistinguish- able, and the tissue a disorganized sanious mass, so thin that several drops ran, by their own gravity, out upon the table. The rest of the brain was healthy. This disorganization was found to extend down to a level with the lateral ventricle and inward almost to the outer margin of the ventricle. The adjacent wood-cut represents the specimen, and shows the vault of the 264 WOUNDS AND INJUEIES OF THE HEAD, cranium, with a disk and twelve fi-agments removed by the trephine fi-om the left parietal bone. The opening of the operation measures three-fourths by one and a quarter inches, and a fissure traverses the bone diagonally from the anterior superior to the posterior inferior angle. The specimen and history were contributed by Acting Assistant Surgeon S. A. Storrow. Case. — Corporal J. C. H — Co. E, 2d New Jersey Volunteers, aged 37 years, was wounded at the battle of Spott- sylvania Court-house, Virginia, May 14th, 1864, by a conoidal ball, which entered the lower part of the occipital bone, fractured and depressed the inner table, and lodged in the diploe, plugging up the lateral sinus on the right side of the brain. He was admitted on the same day to the hospital of the 1st division. Sixth Corps, and thence, on the 19th, sent to the Harewood Hos- pital, AVashington, D. C. On the 21st, the parts were in a healthy condition, with a moderate amount of suppuration, and the patient’s constitutional condition was remarkably good. Surgeon E. B. Bontecou, U. S. V., applied the trephine, but did not remove the ball, for fear of hmmorrhage from the latera] sinus and immediate death. The patient did not exhibit any symptoms of compression until the 26th, when he was seized with convulsions, caused by the depressed portion of bone and the pressure of the ball on the brain. The trephine was again applied, and the depressed bone was removed, but the ball had receded fi’om sight, and could not be found. After the operation, the convulsions ceased, a passive delirium supervened and continued until the 4th of June, 1864, when death occurred. The autopsy revealed a disorganized pulpy condition of the posterior lobe of the brain, emitting an extremely ofi'ensive odor. The fracture extended from orifice of entrance to the foramen magnum. The ball was found in the posterior lobe of the cerebru^r, at the depth of about two inches. The specimen is a large section of the cranium with a conoidal ball suspended in a perforation of the occipital bene. The open- ing measures one inch by one and one-fourth inches, and is partly caused by the operation of trephining. A fissure passes downward and inward to the foramen magnum. The specimen and history were contributed by Surgeon E. B. Bontecou, U. S. V., and are further illustrated in the Surgical Photograph Series, A. M. M., Volume VII, page 1. Fig. 128. — .Section of the occipital hone, with a musket hall, which plugged the lateral sinus. Spec. 3040, Sect. 1, A. M. M. K Co. G, 6th Ohio Cavalry, aged 21 years, was wounded in a cavalry skirmish near Case. — Private P- Middleburg, Virginia, June 21st, 1863, by a carbine ball, which fractured the right parietal bone near the junction of the coronal and sagittal sutures. The bone was depressed one-sixth of an inch. A portion of the ball and several spicultc of bone were removed on the field. The patient w'as conveyed to Washington, D. C., and admitted into Stanton Hospital on the 24th, being pC-rfectly conscious, but complaining of headache. The pupils were normal, deglutition good, pulse accelerated and rather feeble, and the left lower extremity paralyzed. An ice bag was applied to the head, an enema administered, and quiet enjoined. He passed a very I’estless night and on the following morning became delirious, with a pulse at 120. On the 26th, coma was pro- found, respiration stertorous, and slower than natural, the skin hot and dry, and the pulse ranging from 65 to 80. The pupil of left eye was dilated and not responsive to the stimulus of light, that of the right eye was closely contracted, and the conjunctiva injected with blood; the left leg and arm were paralyzed, the micturition involuntary. Surgeon John A. Lidell, U. S. V., made an incision two inches in length, applied the trephine on the light edge of the fracture and cut out a disc of bone, and removed, with an elevator, two fragments of depressed bone; one, about one and a half inches in length by three-fourths of an inch in breadth, embracing both tables of the skull, the other being a small fragment of the inner table. The dura mater at the posterior and external part of the opening was found to be lacerated to the extent of half an inch, and a small quantity of brain tissue escaped. The longitudinal sinus having been uncovered, a copious stream of dark-colored blood came away, apparently flowing from the open mouths of the small veins which run from the cranium into the sinus. The bleeding was checked by a pledget of lint, saturated with a solution of persulphate of iron. The pupil of the right eye expanded to the natural size and that of the left diminished and responded to the light. The engorgement of the conjunctiva of the right eye perceptibly decreased, the stertor disappeared and the breathing became more natural ; the pulse lose to 110, but consciousness did not return. Ice was ‘igain applied to the head and an enema was ordered. The next morning respiration was 60 per minute, and bronchial rattles were audible throughout the chest; pulse 130, and weak ; the left side of the body was rigid, while the right side was moved quite freely. There were convulsive twitchings of right side of face, which, in two hours, extended ■ over the entire light side of the body, while the left side lost its rigidity, but was not affected by convulsive movements. In the meantime the breathing became more frequent and feeble, and the patient died at five o’clock P. M., June 27th, 1863. At the autopsy, an elongated opening in the calvaria was exposed, half an inch long and three-fourths of an inch in width, commencing one-fourth of an inch behind the coronal suture and ex- tending backward and a little to the right of the median line. The dura mater was lacerated to the extent of half an inch at the posterior end of the chasm in the skull. On raising that portion of the dura mater which covers the convex surface of the right hemisphere of the cerebrum, a quantity of coagulated blood was found m the cavity of the arachnoid, spread out over the convexity of the right hemisphere ; the largest quan- tity of effused blood was found at the base of the middle and posterior lobes of the right hemisphere. The effused blood, which was very dark, amounted, in all, to three ounces, and came from the longitudinal sinus. The whole brain showed very great venous congestion. There was softening of the brain tissue at the seat of injury, near the summit of each cerebral hemisphere, but it was more marked on the light than on the left side. The pathological speci- men is No. 1333, and was contributed, with the history, by Surgeon John A. Lidell, U. S. V. This case is erroneously reported as a sabre cut, in bound MSS. Div, Surg. E( c. S. G. O. No. 63, p. 22. Fig. 129. — Segment of vault of cranium trephined near the longitudinal sinus. Spec. 1333, Sect. I, A. M. M. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 265 Case. — Private J. L- Fir:. 130. — Section i f a skull nuieh shattered by gunshot, and trephined. Rptc. 2000, Scot. I, A. M. M. Co. A, 122(1 Ohio Volunteers, aged 28 years, ivas wounded at the battle of Mine Run, Virginia, November 27th, 1863, by a conoidal ball, which entered the frontal bone, just above the inner canthus of the right eye, passed downward and inward, and made its exit through the outer wall of the left antrum of Highmore. He was treated in a field hospital for several days, and on December 4th, admitted to the 3d division hospital at Alexandria, Virginia. His condition had been good, but he soon became comatose. On December 8th, Surgeon E. Bentley, U. S. V., applied the trephine and removed a disk of bone from the centre of the frontal bone betwewi the superciliary ridges. Splinters of bone, consti- tuting nearly all the nasal and left malar bones, were removed at the same time. No relief was afforded, and the patient died on December 13th, 1863. The pathological specimen, which shows a section of skull trephined for extensive fracture of frontal and facial bones, together with the history, was contributed by the operator. Case. — Private M. M , Co. C, 48th Pennsylvania Volunteers, aged 45 years, was wounded at the battle of Spottsylvania Court-house, Virginia, May 12th, 1864, by a conoidal ball, which comminuted and depressed the left parietal bone near the upper border to the left of the longitudinal sinus. He was admitted to the hospital of the Ninth Corps and thence sent to the Carver Hospital, Washington, on tli^ 14th, somewhat morose and taciturn, and at times manifesting slight symptoms of compressions, but expressing himself quite intelligibly. On the evening of the 15th, he became decidedly comatose. On the following morning the patient was placed under the influence of ether. Acting Assistant Surgeon J. O. French trephined the skull over the afiected region and removed several large splinters of the external table. The depressed portion was of an irregular quadrangular shape, measuiing an inch or more in its longest diameter, and was firmly imbedded in the brain. The mem- branes and medullary substance of the brain were lacerated by the depressed frag- ments, accounting for the slight oozing of medullary substance and blood that had existed ever since his admission. Considerable hmmorrhage occurred during the operation, which was controlled by dry lint. The operation relieved the patient from his comatose condition, and he became quite animated, remaining so until the 18th, when coma again set in. Death supervened on the 20th. The autopsy revealed traces of meningeal inflammation and infiltration of purulent matter in the region of the injury. The left lateral ventricle was distended with blood, and a small piece of bone was found projecting into its cavity. The pathological specimen is a disk and three fragments of bone, removed from the cranium. The largest fragment is from the inner table and measures one inch in diameter. The specimen and history were contributed by Surgeon O. A. Judson, U. S. V. Case. — Private A M , Co. D, 155th Pennsylvania Volunteers, was wounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a conoidal musket ball, which entered at the juncture of coronal and squamous sutures, and lodged. He was admitted to the Patent Office Hospital, Washington, D. C., on the 17th, complaining but very little of his wound, and was able to walk about until the 19th, when the pain became so severe that he was compelled to take to his bed. He became restless, showing all the symptoms of febrile excitement. A lotion of lead water and laudanum was ordered to be applied to the wound, and an anodyne administered. Up to this time he had not been delirious and was able to give rational answers to all questions. On the morning of the 20th, he was comatose and all the symptoms of compression of the brain were well marked; his eyeballs, especially the right, were prominent and the pupils fixed and contracted. On removing the dressing, blood and brain substance oozed from the wound. The wound of the scalp was then enlarged and the skull trephined ; spiculae of bone were removed, causing considerable hsemor- rhage, but no relief to the patient. He died a few hours after the operation. The post-mortem examination revealed cerebro-meningitis, advanced to the stage of suppuration, pus having collected over the anterior surface of the brain, and between the pia mater and arachnoid. The ball had lacerated the anterior portion of the middle lobe of the brain, the terminal branches of the internal carotid, and the anterior branch of the temporal artery. There was a large clot on the floor of the middle fossa of the cranium. A fragment of the ball was found in the centre of the middle lobe of the cerebrum, and the remaining portion was imbedded in the sphenoid bone. The patliological specimen is figured in the wood-cut. The opening in the cranial wall measures one inch from above downward and is three-fourths of an inch wide ; from this point one fissure passes downward across the glenoid cavity and a second forward into the external wall of the right orbit, which is c<^m- Fig. 132. — So^nent of cranium and p<(rtion of lower minuted. The ball is encrusted with calcareous matter. Acting Assistant "is"* 800^1^*^! **'^'*" Surgeon J. H. Jamar contributed the specimen and history. 34 Fig. 131. — Disk and fragments of skull re- moved by trephining. yect. I, A. A. [Nat. size.] 266 WOUNDS AND INJURIES OF THE HEAD Case. — Private Edward Noi ton, Co. I, 39th New Jersey Volunteers, aged 21 years, was wounded at Petersburg, Virginia, April 2d, 1805, by a shell which fractured the right parietal bone. He was conveyed to tbe field hospital of the 2d division, Ninth Corps, thence sent to City Point, Virginia, where he remained until the Cth, when he Avas conveyed to the Fairfax Sem- inary Hospital, Virginia. No symptoms of compression existed. The external Avound Avas one and a half inches in length ami had a bad aiipcarance. Water dressings Avere applied and beef tea ordered. On the Gth, the patient’s appetite failed, deglutition became ditficult, and symptoms of eflusion appeared on the ftdloAving day. Surgeon D. P. Smith, U. S. V., applied the trephine and removed a portion of the cranium and several fragments, greatly I'elieving the symptoms. The patient talked better and answered questions correctly. Hernia cerebri Avas first noticed on the morning of the 11th, and on the 12th, a slight heemorrhage occurred. Coma folloAved ; the protruding hernia Avas removed, but death ensued on April 14th, 1865. The case is reported by Surgeon David P. Smith, U. S. V. Case. — Corporal E. B. P , Co. H, 14th Connecticut Volunteers, aged 20 years, Avas Avounded at the battle of Fred- ericksburg, Virginia, December 13th, 1862, by a musket ball, Avhich fractured both tables of the os frontis in the median line, one inch beloAV the anterior extremity of the sagittal suture. He Avas admitted to the Armory Square Hospital, Washington, on the 20th. Symptoms of compression of the brain appeared in a feAV days. An examination revealed a piece of lead, impacted in the os frontis, one-half of an inch beloAV the anterior extremity of the sagittal suture. On the 29th, Surgeon D. W. Bliss, U. S. V., applied the trephine over the seat of injury and removed the portion of bone containing the fi-agment of lead, giving exit to a large quantity of sanguineous pus. Immediately beneath the trephined portion of bone, a depressed fragment of the inner table Avas found, measuring three- fourths of an inch in diameter, which Avas I’emoved. Cold Avater dressings Avere applied, cathartics administered, and low diet ordered. The patient lingered in a semi-comatose condition until the 31st, Avhen death ensued. The autopsy revealed the inner talde much fractured, and spiculse driven into the substance of the brain. A large collection of pus existed beneath the dura mater. The pathological specimen is 625, Sect. 1^ A. M. M., and Avas contributed, Avith the history, by Surgeon D. W. Bliss, U. S. V. Case. — Private W'illard P , Co. I, 120th Nbav York Volunteers, aged 18 years, Avas Avounded near Hatcher’s Run, Virginia, March 25th, 1865, by a conoidal ball, Avhich fractured and depressed the right ])arietal bone near the sagittal suture. He AA’as, on the same day, taken to the hospital of the 3d division. Second Corps, and theKce conveyed to Washington, and admitted to the Emory Hospital, on the 5th of A])ril. On the folloAving day, he was ]daced under the inlluence of chloroform, and Surgeon N. R. Moseley, U. S. V., trephined and elevated the fractured portion of the parietal hone. Cold Avater dressings and compresses Avere applied, enemas administered, and nutiltious diet ordered. On the 13th, the patient Avas apparently doing well, but death supervened on April 17th, 1865, from exhaustion. The pathological specimen is No. 4074, and shoAVS a disk and tAVO fragments of bone from the right parietal. The fragments are chielly from the inner table, and include one-half square inch of surface. The specimen and history Avere contributed by Surgeon N. R. Moseley, U. S. V. Case. — Corporal H. L. P , Co. I, 1st Massachusetts Heavy Ai tillery, aged 20 yeai's, Avas Avounded at Petersburg, Virginia, June 17th, 18G4, by a conoidal ball, Avhich struck the left jiarietal bone at its posterior superior portion, causing, apparently, only a Avound of the scalp tAvo inches in length. He Avas convej'ed to Washington, and admitted to the IlarcAvood Hospital on June 21st, and thence transferred, on the 27th, to the Satterlee Hospital, Philadelphia. He appeared to be perfectly Avell, but on the morning of the 3d of July, he Avas found speechless and paralyzed. An examination revealed the cranium denuded of its periosteum and several small pieces of lead firmly fixed in the b(jno. Acting Assistant Surgeon W. F. Atlee applied the treplune and removed a portion of the outer table of the cranium at the seat of injury. Some improvement in the motions of the tongue Avas noticed and further proceedings Avere suspended. On the folloAving d.ay the inner table Avas trephined, revealing an OA’al shaped fissure one inch in its long, and half an inch in its short diameter, Avhich Avould admit the introduction of a finely pointed quill toothpick. The bone, inclosed by the fissure, Avhich Avas loosened and depressed, Avas removed. No relief, liOAvever, Avas afforded, and death occurred July 7th, from compression of the brain. The patient had been perfectly rational througbout the treatment. An autopsy revealed a large abscess filled Avith pus extending from the top of the left cerebral hemisphere to its base. Tbe pathological specimen is No. 3635, Sect. I, A. M. M., and Avas contributed by Acting Assistant Case. — Corporal G. H. S , Co. C, 18th Massachusetts Volun- teers, Avas Avounded at the battle of Chanccllorsville, Virginia, May 3d, 1883, by a conoidal musket ball, Avhich fractured and depressed the fi’ontal and the left parietal bones at the junction of coronal and sagittal sutures, one inch from the median line. He Avas immediately admitted to the Fifth Corps field hospital, and transferred, on May 9th, to the Finley Hospital, Washington, in good condition, Avith slight cerebral symptoms. On the 15th, he Avas placed under the influence of ether ; the trephine Avas then apjdied and the external table elevated, but further operation Avas sus- pended, as no fi’acture or depression of the inner table could be discovered. On the next morning convulsions occurred and continued at intervals. The patient became insensible and the pupils dilated. Erysipelas of the scalp and face supervened ; and these symptoms continued unchanged until May 17th, 1863, Avhen death occurred. The post-mortem examination revealed a stellate fracture and slight depression of the inner table of the frontal and left parietal bones, but more extensive than that of the outer table. The brain under and around the injury Avas considerably discolored, and softened in both hemispheres. The pathological specimen, Avith its history, Avas contributed b^' Acting Assistant Surgeon Alfred Edelin. Surgeon George Kerr, Avho reports the case. TEBPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 267 Case. — Private Jacob Smith, Co. D, 48tli Peimsylvania Volunteers, aged 33 years, was wounded in the engagement near Fort Steadman, Virginia, April 2d, 1865, by a conoidal musket ball, which struck the centre and upper part of the frontal hone, making a vertical incision of the scalp two inches in length. The pericranium was only slightly detached and no fracture was observable. He was taken to the hospital of the 2d division. Ninth Corps ; on April 4th, sent to Carver Hospital, Washington, and on May 19th, transferred to Mower Hospital, Philadelphia. Three days later, the right temporal region became swollen, and erysipelas, attended with high fever, quick pulse, and delirium, supervened. An abscess being suspected, an incision was made in the temple, but none could be found. A brisk cathartic was given, and the face and head dressed with sol. sod. sulph. On May 24th, the left side of the head became involved and head symptoms developed rapidly. Chloroform being administered, a crucial incision was made by Acting Assistant Surgeon W. P. Moon, and the bone exposed, when the slightest perceptible fissure in the external table was discovered, from which a thin sanious discharge was issuing. Upon removing a portion of the two tables with a trephine, it was ascertained that the fissure extended through both tables, without fracturing or depressing either. Quite an amount of pus escaped from the orifice and considerable disorganization was evident. Death occurred on May 25th, 1865. At the autopsy, the interior lobes were found greatly congested, with formation of pus over a great extent of the longitudinal sinus. All the vessels of the membranes were much enlarged and engorged, and at the point of injury disorganiza- tion had taken place. The case is reported by the operator. Acting Assistant Surgeon W. P. Moon. Case. — Lieutenant W. V , Co. L, 1st Maine Heavy Artillei-y, aged 30 years, was wmunded at the Battle of Spott- sylvania Court-house, Virginia, May 17th, 1864, by a conoidal ball, which fractured and depressed both tables of the left pai-ietal bone. He was admitted into the Emory Hospital, Washington, on the 22d, in a comatose condition, with paralysis of the right side. The scalp was lacerated and sloughing, the pericranium torn, and spiculae of bone had been driven in upon the dura mater. The membranes of the brain were entire. Surgeon N. R. Moseley, U. S. V., applied the trephine, removed two fragments of bone and elevated the depressed portions. Beef tea and liquid stimulants were administered. Inflammation of the meninges supervened, and the patient died on the 24th of May, 1864. The post-mortem examination revealed a fracture, extending from the opening made by the trephine toward the left parietal bone. The substance of the brain was softened and congested with dark, livid blood. The pathological specimen. No. 2317, Sect. I, A. M. !M., shows a disk and five small fragments of bone removed from the left parietal. The disk is split transversely. The specimen and history were contributed by Surgeon N. R. Moseley, U. S. V. Case. — Private J W , Co. K, 1st Michigan Volunteers, aged 30 years, was wounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a missile supposed to have been a musket ball. On admission to the Hammond Hospital, Point Lookout, Maryland, December 16th, a lacerated wound of the scalp was found, of triangular shape, with the apex situated anteriorly on the inferior border of the right parietal bone, an inch above the top of the ear. At the base of the wound a fracture and depression of both tables of the skull was detected, the fracture covering an irregular space of about an inch in diameter. The patient experienced little or no uneasiness from the injury, and all symptoms of cerebral lesion were absent. The wound was dressed with cold water, and rest and low diet ordered. No change took place until the 27th, when the man became drowsy and could be aroused to answer questions only with great difficulty, relapsing immediately into a sleepy condition. 'The pupils were somewhat dilated, and he complained of a feeling of numbness in the whole left side of his body; there was, however, no complete paralysis; pulse about 60 and natural. Chloroform was administered, the seat of fracture exposed, and Acting Assistant Surgeon Charles L. Hogeboom applied the trephine at the posterior border and removed several depressed fragments. The symptoms of compression disappeared, and the case progressed favorably until the 5th of January, 1863, when the signs of compression returned, the patient becoming partially insensible and inclined to vomit. The breathing became stertorous, the pupils dilated, and the pulse weak and irregular. He sank rapidly and died on the following day. No marked paralysis existed at any time, the nearest approach being the feeling of numbness mentioned on the day of the operation. O^i removing the scalp, at the autopsy, two fissures were discovered diverging from the seat of the fracture; one passing from near where the trephine was applied backward across the lateral and posterior aspect of the skull, and ending just above the external occipital protuberance, the other commencing at the anterior border of the opening in the skull and passing forward and down- ward for the distance of an inch. The dura mater was entire, but softened at the seat of the fracture. The cerebral substance was softened to the depth of one-fourth of an inch and of a yellowish color. There was, also, considerable injection of the vessels of the membranes and of the substance of the brain. The ventricles were filled with serum. The specimen, which is illustrated in the annexed wood-cut was contributed, with the history, by Assistant Surgeon Chnton Wagner, U. S. A. Case. — Sergeant A B , Co. A, 5th Michigan Volunteers, aged 24 years, was wounded at the battle of Mine Run, Virginia, November 27th, 1863, by a conoidal ball, which fractured the right side of the frontal bone, just below the temporal ridge. He remained in the field hospital until the 4th of December, when he was transferred to the 3d division ho.spifal, Alexandria, Virginia, in a perfectly natural condition. He continued so until the 8th, when the skull was trephined. The ball Fio. 135. — Calvaria trephined for gunsliot fmctnrc. Spec. 924, Sect. I, A. M. M. Fig. 134. — Disks and fraginenfs removed from left parietal. Spec. 117, Sect. I, A. M. M. [Kat. size.] 268 WOUNDS AND INJURIES OF THE HEAD liad been removed on the field. For forty-eight hours after the operation, lie was, at intervals, slightly delirious; he recovered at the end of that time, and continued in full possession of his mental facullies until the 14th, when stupor and comasuiiervened ; he died on the same day. The pathological specimen is No. 2G1‘J, Sect. I, A. ]\I. M. Fragments have been removed from the cranium for a space measuring one by one and one-fourth inches. The inner surface of the edge of the opening is slightly cribriform. There is no fissuring. The history and specimen were contributed by Surgeon E. Bentley, U. S. V. Ca.se. — Private J. H. D , Co. B, 2d New York Heavy Artillery, received at Cold Harbor, Virginia, on the 7th of June, 18G4, a gunshot fracture of the right jiarietal bone causing slight depression. He was at once admitted to the 1st division. Second Corps, hospital, and transferred to the Fairfax Seminary Hospital, Virginia, on June 8th, complaining of headache. Surgeon D. P. Smith, U. S. V., a]iplied the trephine and removed a disk and six fragments of bone. Water dressings were applied to the wound, which suppurated freely. An abscess formed in the brain, and the patient died on June 10th, 18G4. The pathological specimen is No. 3305, Sect. I, A. M. M., and was contributed by the operator. Case. — Pi ivate James A. Winn, Co. B, 13th Tennessee Cavalry, aged 22 years, was wounded at Fort Pillow, Tennessee, April 12th, 18G4, by a rifle ball which passed from right to left, across the top of the head, fi-acturing the cranium. On the 14th he was admitted into the general hospital at Mound City, Illinois. During the night of the ICthj he had a severe headache, but otherwise was doing well until twelve o’clock P. SI. of the 19th, when he became delirious. Htemorrhage from the middle meningeal artery occurred, causing a loss of about twenty-four ounces of blood. Spasms supervened. On the following morning the patient was placed under the influence of ether and chloroform, and Surgeon Horace Wardner, U. S. V., applied the trephine over the left parietal bone, half an inch to the left of the sagittal suture, elevating a piece of bone one inch in diameter. Three or four ounces of blood were lost during the operation. Paralysis of both extremities of the right side set in, and the convulsions continued until twelve o’clock M., of the 21st, when death supervened. At the post mortem it was ascertained that the ball had passed through the cranium, but the missile could not be found. A piece of the inner table, one inch in length and three-fourths of an inch in width, was entirely detached and was adherent to the dura mater. Extensive extravasation of blood and serous effusion of water to the amount of three ounces existed under the left parietal bone. The path- ological specimen is No. 3308, Sect. I, A. M. M., and was contributed, with the history, by Surgeon H. Wardner, U. S. V. Fig. 136. — Calvaiia trephined for clepre.secd fracture by a musket ball. Spec. 3308, Sect. I, A. M. M. Case. — Private Frederick E , Co. M, 4th Pennsylvania Cavalry, aged 38 years, was wounded near Petersburg, Virginia, November 25th, 18G4, by a conoidal ball, which penetrated the right parietal bone near the superior border and emerged near junction of the occipital and parietal bones. He was admitted to the hospital of the 2d division,* Cavalry Corps, on December 1st; on the 9th, sent to the Cavalry Corps Hospital, Anny of the Potomac, and on the 15th, transferred to the Aimory Square Hospital, Washington. On December 16th, he was placed under chloi’ofoim and his skull trephined by Surgeon D. W. Bliss, U. S. V. The edges of the wound were brought together with straps, and the patient rallied well from the operation. During the following day he complained of pain in the head and was slightly delirious. On the morning of the 20th, he ate a hearty breakfast, then fell into a profound stupor, from which he never recovered. Complete paralysis of the left arm and partial paralysis of the left leg supervened ; hernia cerebi i also appeared, and death occurred on December 20th, 18G4. The pathological specimen is No. 351G, Sect. I, A. M. M., and consists of a disk of bone from the parietal one inch in diameter. The specimen and history were contributed by Surgeon D. W. Bliss, U. S. V. Case. — Ihivate H. A , Co. B, 3Gth Illinois Volunteers, aged 22 yerrs, was wounded at Resaca, Georgia, May 14th, 18C4, by a conoidal ball, which fractured and slightly depressed the right parietal bone at its centre. He was admitted on the same day to the hosjJtal of the 2d division. Fourth Corps; transferred to Chattanooga, May IGth, and thence sent to Hospital No. 1, Nashville, Teiines.see, on the 19th. He complained of a dull pain in the head, which continued until the 18th of June, when ho became comatose. On June 21st, Acting Assistant Surgeon H. C. May applied the trephine over the seat of fracture, and removed several fragments of necrosed bone from the meninges. The tissues had been destroyed by gangrene over a space of about two inches in every direction from the wound, which was granulating finely. The patient never fully reacted after the operation; he became lethargic, sank rapidly, and died on June 22d, 18G4. At the autopsy, the mem- branes beneath the fracture were found dark colored and thickened. Beneath this and in the substance of the hemisphere existed a large abscess, which communicated with the lateral ventricles, and was fiUed with highly oflbnsive pus. The specimen is figured in the wood-cut, and consists of a disk and six fragments of bone, embracing about one- half S([uare inch of the parietal bone. The specimen and history were contrilmt(‘d by Acting Assistant Surgeon 11. C. May. after (run li t fraclure. Spec. 33(52, Sect. I, A. 3!. 3>. TREPHINIKG AFTER GUNSHOT FRACTURES OF THE SKULL. 269 Case. — Private James Addison, Co. B, 19th United States Colored Troops, received, near Petersburg, Virginia, August 19th, 18G4, a severe gunshot wound of the cranium. He was admitted to hospital 4th division. Ninth Corps, where the trephine was applied, and three inches of the occipital and left parietal bone were removed. He died on August 19th, 1864. Case. — Private James Bans, Co. E, 17th Maine Volunteers, aged 23 years, was wounded at the battle of Mine Eun,_ Virginia, November 27th, 1863, by a conoidal ball, which fractured and depressed both tables of the left parietal bone. He was admitted into the 3d division hospital, Alexandria, Virginia, on December 5th. He was speechless; still could be aroused sufficiently to answer by signs, but would immediately relapse into stupor. His pulse was slow, soft, and irregular ; bowels torpid, and deglutition difficult. On the following day. Surgeon Edwin Bentley, U. S. V., removed the depressed portion of bone with the trephine, while the patient was under the influence of ether. He recovered his speech after the operation, and com- plained of pain in his head. On the 10th his right lung became painful ; stupor gradually supervened, extensive inflammation set in. and death ensued on the 13th of December, 1863. The autopsy revealed eflTusion of coagulable lymph and serum into the cavity of the arachnoid, and the brain softened and congested. Acting Assistant Surgeon \V. G. Elliott reports the case. Case. — Private Frederick Buck, Co. D, 52d Pennsylvania Volunteers, was wounded at the battle of Fair Oaks, Virginia, May 31st, 1862, by a conoidal ball, which penetrated the left side of the os frontis, and lodged in the brain substance. He was admitted to the hospital of Gen. Casey’s Division, Fourth Corps, and thence transferred to the general hospital at Newport News, Virginia, on June 4th, 1862, in a comatose condition. The skull was trephined, and the ball and fragments of bone were removed, but death ensued on June 9th, 1862. The case is reported by Surgeon A. B. Shipman, U. S. V. Case. — Private Jasper W. Burton, Co. C, 7th West Virginia Volunteers, aged 23 years, received, near Swift Run, Virginia, May 30th and 31st, 1864, a gunshot depressed fracture of the frontal bone. He was admitted to the hospital of the 3d division. Second Corps, where the operation of trephining was performed by Surgeon H. A. Martin, U. S. V. The patient died shortly afterward. Case. — Private Llenry S. Brandt, Co. K, 7th Connecticut Volunteers, aged 32 years, was wounded at Bennuda Hundred, Virginia, June 2d, 1864, bj' a conoidal ball, which fractured and depressed the cranium over the longitudinal sinus. He was admitted on the 4th into the general hospital at Hampton, Virginia, and transferred on June 8th, entering DeCamp Hospital, David’s Island, New York Harbor, on the 10th. Coma had supervened on the 19th, when Assistant Surgeon Warren Webster, U. S. A., applied the trephine, and removed a portion of the fractured bone, revealing extensive comminution of the inner table. Simple dressings were applied, but death occurred a few hours after the operation, from compression of the brain. A post-mortem examination revealed the brain much engorged. Case. — Private John Blood, Co. A, 7th New York Artillery, was wounded at Deep Bottom, Virginia, August 14th, 1864, by a shell, which severely injured the cranium. He was admitted to hospital 1st division. Second Corps, where the trephine was applied and pieces of bone were removed. He was taken on board of a transport on August 18th, 1864, but died shortly afteiAvard. Case. — Captain Allen A. Burnett, Co. K, 37th Wisconsin Volunteers, aged 38 years, was wounded at Petersburg, Virginia, July 30th, 1864, by a shell, which fractured the frontal bone, right side; he received at the same time a wound in the left shoulder. The skull was trephined upon the field by Surgeon. W. B. Fox, 8th Michigan Volunteers, and the patient was sent to Washington, entering Armory Square Hospital on August 1st. Hsemon’liage occurred on August 14th, from one of the branches of the cerebral arteries and was arrested by a ligature. Plis strength gradually failed, and death occurred on August 16th, 1864. The case is reported by Surgeon D. W. Bliss, U. S. V. Case. — Corporal Orville Bannister, Co. I, 8th New York Heavy Artillery, aged 18 years, was wounded at the battle of Petersburg, Virginia, June 22d, 1864, by a piece of shell, which caused a penetrating fracture of the cranium. He was admitted to the 2d division. Second Corps, hospital, where the trephine was applied by Surgeon S. Hiram Plumb, 82d New York Volunteers. The patient was transferred to the Campbell Hospital, Washington, June 28th, and died on July 1st, 1864. Case. — Corporal George C. Chase, Co. F, 8th New York Heavy Artillery, aged 21 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a fragment of shell, which fractured the cranium, driving about sixty fragments of bone through the dura mater to the depth of about half an iuch into the brain substance. He was, on the same day, admitted to the hospital of the 2d division, Second Corps; on June 8th, transferred to the Columbian Hospital, Washington; and on June 19th, sent to the McDougall Hospital, New York Harbor. Inflammation of the brain set in, and, on June 30th, chills occurred. On July 4th, fragments of bone were removed, and on July 7th, the operation of trephining was performed. Death occurred on July 7th, 1864. Case. — Private Milford Clark, Co. C, 12r)th New York Volunteers, aged 20 years, was wounded at Spottsylvania, Virginia, May 18th, 1864, by a conoidal ball, which struck the cranium half an inch above the frontal eminence, and passed posteriorly four inches, lacerating the scalp in its course. He was admitted into the 1st division, Second Corps, hospital on the same day, and thence sent to the Armory Square Hospital, Washington, on the 28th, where the wound was carefully examined and a fissure of the outer table one inch in length, discovered. The operation of trephining was at once instituted, and the depressed portion- of the inner table elevated. Death, preceded by coma, however, ensued on June 25th. Surgeon D. W. Bliss, U. S. V., reports the case. Case. — Private William Cole, Co. I, 50th Pennsylvania Volunteers, was wounded at the siege of Knoxville, Tennessee, November 19th, 1863, by a conoidal ball, which penetrated the brain. lie was conveyed to the field hospital of the Ninth Corps, where Surgeon James I’. Prince, 3fith Massachusetts Volunteers, treidiined the skull, and removed a piece of bone one inch in diameter. Death supervened 1. 272 WOUNDS AND INJURIES OF THE HEAD, Case. — Private William II. Ililborn, Co. K, SCtli Now York Volunteers, aged 23 years, was wounded at the battle of Mine Run, Virginia, November 27tb, 18G3, by a conoidal ball, which fractured the angle of the frontal bone, on the left side of the head, and lodged. He was admitted to the 1st division. Third Corps, hospital on the same day, and transferred to the 3d division hospital, Alexandria, Virginia, on December 4th. Four days later the skull was trephined, but the patient sank gi'adually into a comatose condition, and died on the 13th. The autopsy revealed the ball, lying impacted between the hard and soft palates. The case is reported by Acting Assistant Surgeon A. G. Smith. Case. — Sergeant William N. Irvin, Co. B, 1st battalion, 1st Minnesota Volunteers, aged 25 years, was wounded on June 18th, 18C4, near Petersburg, Virginia, by a conoidal ball, which entered the frontal bone, in the immediate vicinity of the lef frontal eminence, passed inward, and lodged. He was conveyed to the field hospital of the 2d division. Second Corps, and on June 22d, transferred to the Carver Hospital, Washington. On June 25th, he was placed under the influence of ether, and Surgeon O. A. Judson, U. S. V., removed sequestra, trephined the edge of the fracture, and removed several pieces of cloth and the missile from the interior of the cranium. The liacture was neatly circular, and about one inch in diameter. Considerable swelling existed in the immediate vicinity of the wound, and the left upper eyelid was ocdematous. The patient reacted promptly, and appeared to be quite easy ; there being no cerebral symptoms or coma. During the day, however, he was attacked with delirium, which contiued unabated until June 28th, 1864, when death ensued. The autopsy revealed a compound comminuted fracture of both tables of the os frontis, the missile having passed through the membranes of the brain, slightly wounding the left hemisphere of the cerebrum. The brain was completely disorganized; it being a reddish, granular mass. Both lateral ventricles were distended with pink fluid. A coating of lymph was found covering the dura mater at the base of the brain. The case is reported by Surgeon O. A. Judson, U. S. V. Case. — Corporal John Johnson, Co. G, 8th Iowa Volunteers, aged 20 years, received, at Shiloh, Tennessee, April 6th, 1832, a compound fracture of the skull. He was conveyed to the field hospital, 2d division. Thirteenth Corps, and subsequently transferred to Paducah, Kentucky. The skull was depressed, and the patient suffered from compression of brain and erysipelas. On April 15th the operation of trephining was performed, but death supervened twenty-four hours after the operation. Case. — Private A. Kirl-patncTc, Co. II, 44th Tennessee Regiment, received, at the battle of Perryville, Kentucky, October 8th, 1862, a severe gunshot fracture of the cranium, with large depression. He was, on the same day, admitted to the Confederate hospital at Perryville, where the skull was trephined, and several spiculm of bone were removed. He died on October 30th, 1862. At X\\(i post-mortem, examination, many spiculm of bone and abscesses below the dura mater evere discovered. The case is reported by Surgeon D. W. Yandell, P. A. C. S. Case. — Private William Lentz, Co. K, 14th Iowa Volunteers, received, at Fort Donelson, Tennessee, February 13th, 1862, a severe gunshot wound of head. He was admitted to regimental hospital, where the operation of trephining was performed. No particulars are reported. He died on March 6th, 1832. Case. — Captain W. W. Liggett, Co. H, 12th Ohio Volunteers, received, at the battle of South Mountain, Maryland, September 14th, 1862, a gunshot fracture of the top of the arch of the cranium. The dura mater was badly torn by the missile. He was at once admitted to the field hospital at Middletown, where the operation of trephining was performed by Surgeon John McNulty, U. S. V., on the same day. The patient W’as rational on the morning following the operation, but died on September 21st, 1862. Case. — Private Charles H. Leonard, Co. H, 57th Massachusetts Volunteers, aged 22 years, was wounded at the battle of the Wilderness, Virginia, May 6th, 1864, by a conoidal ball, which fi-actured the left parietal bone at its eminence. He was conveyed to Washington, and entei-ed Columbian Hospital on May 11th. TJie wound was in good condition, the bone being slightly fractured but not depressed, but the patient was nearly comatose and greatly prostrated. On May 15th, Acting Assistant Surgeon H. D. Vosburg removed portions of the left parietal bone with the trephine, and then took out a fragment of the inner table, which was lying loose on the dura mater. Stimulants and nourishment were freely administered, but the coma became gradually more complete, and the patient died on May 17th, 1864, from cerebritis. Case. — Corporal Philander D. L , Co. II, 1st Maine Heavy Artillery, aged 28 years, was wounded at the battle of Spottsylvauia Court-house, Virginia, May 19th, 1864, by a conoidal ball, which inflicted apparently only a lacerated wound of the scalp, over the superior anterior angle of the left parietal bone.* He was conveyed to Washington, and on the 23d, admitted to the Araiory Square Hospital. On examination the external table was found to be fissured and denuded of periosteum. Up to May 30th the patient did not show any symptoms of compression of the brain, but on that day he had a chill. On the 31st he. was placed under the influence of, ether. Surgeon D. W. Bliss, U. S. V., then applied the trephine over the seat of injury, and excised a disk one inch in diameter, including only the outer table and diploii. The inner table of the skull was found to be intact, but friable and easily broken. Several pieces of this were removed, as was also a clot which had formed between the inner table and the dura mater. Simple dressings were applied and tonics administered, but pyaemia set in, and death ensued on June 8th, 1864. The specimen is represented in the wood-cut, and consists of a disk and five fragments of bone. The largest fragment is from the inner table, and measures three-fourths by one and one-fourth inches. The disk is one inch ixi diameter, and includes the outer table and diploii only. The specimen and history were contributed by Surgeon D. W. Bliss, U. S. V. *Auother repert frcni the Ariin ry Sisk and five fragments from left parietal, removed hy trephining after gunshot fracture by a musket ball. Spec. 2383, Sect. I, A. M. M. [Nat. size.] TKEPIIINTNG AFTER GUNSHOT FRACTURES OF THE SKULL. 273 Cask. — Private Franldin Leliniaii, Co. F, 184tli Pennsylvania Volunteers, aged 22 years, was wounded before Peter.sbnrg, Virginia, October 1st, 18(54, by a conoidal musket ball, wbicb fractured tbo frontal bone. He was at once admitted to tbo hospital of the 2d division. Second Corjis, where the skull was trephined, the ball removed, and cold water dressings were a]5pliod. He was conveyed to Washington, and admitted on the 8tb into the Campbell Hospital. Death resulted on Octobe*17tb, 1864. Cask. — Private William Lynch, Co. F, 122d Illinois Volunteers, aged 22 years, was wounded near Nashville, Tennessee, December ICth, 1864, by a musket ball, wbicb penetrated tbe frontal bone. He entered the Cumberland Hospital. Nashville, Tennessee, on tbe following day, and w.as on tbe 18tb transferred to Hospital No. 4, New Alb.any, Indiana. Tbe wound evinced no disposition to beal, small quantities of pus escaping continually from tbe external opening. Tbe patient became comatose, tbe pupils contracted, and secretions scant. On January 3d, 18G5, Acting Assistant Surgeon Jobn Sloan trepbined tbe skull at tbe seat of injury. Water dressings were applied to tbe wound, and stimukants administered. Tbe operation failed to relievo tbe coma, and tbe patient died on Janu.ary 4tb, 1865. Tbe autopsy revealed an eflusion of pus from tbe seat of injury to tbe base of tbe brain. Tbe case was reported by Acting Assistant Surgeon S. J. Alexander. Cask. — Private H. S. McC , Co. A, 4tb Georgia Regiment, aged 27 years, w.as wounded at tbe battle of Cbancellorsville, Virginia, M.ay 3d, 1863, by a conoidal ball, wbicb fr.actured tbe frontal bone two inebes above tbo internal cantbus of tin; right eye. Tbe internal table was comminuted. He was admitted into Lincoln Hospital, Wasbington, on tbe 7tb, being rather stupid, but not complaining of pain. These symptoms continued until tbe evening of tbe 14tb, when be appeared to be in a comatose condition, and began to pass bis urine involuntarily. On May 15tb, at four o’clock P. M., bis skull was treiibined, and tbe depressed portions of tbe outer and fragments of tbe inner table were removed, giving exit to a quantity of iluid resembling pus in color and consistency. Tbe comatose condition was relieved by tbe operation, but de,atb supervenearietal bone at its inferior and external angle, injuring the brain subst;mce. He was admitted into the field hospital at Murfreesbon)’, Tennessee, on the same day, being conscious, though dull and unsteady' in his gait. Surgeon I. Moses, U. S. V., trephined the skull, removed all loose fragments, and elevated others. The external table W’as fractured and depressed one square inch; the depression of the inner table W’as more extensive. Ho rallied well from the operation, and the symptoms w’ere apparently favorable until July 3d, when coma, and, shortly afterw’ard, death, supervened. The case is reported by the operator. Case. — Pi ivate David Piatner, Co. C, 39th New York Volunteers, was wounded at the battle of Cold Harbor, Virginia; June 1st, 1884, by a cotioidal ball, which fractured the cranium. He was on the same day admitted to hospital of the 1st division. Second Corps, where Surgeon P. E. Hubon, 28th Massachusetts Volunteers, trephined the skull. The result is not known, but the patient probably’ died. Case.- — Private John Quinlin, Co. H, 2d Illinois Cavalry, aged 28 years, received, on April 8th, 1864, at Pleasant Hill, Louisiana, a gunshot fracture of both tables of the anterior portion of the left parietal bone. He was admitted into tbe field hosj)ital of the cav.alry division, and thence conveyed to New Orleans, Louisiana, and admitted into the Marine Hospital on A])ril 14th. The following morning he comjdained of headache, which gradually’ increased, and (he fiice w’as in an erysipelatous condition. On the morning of the 20th, vomiting set in, and in the afternoon coma supervened. On A])ril 21st, Surgeon Jacob Bockee, U. S. V., performed the operation of trephining, in order to relieve .sy’inptoms of compres.sion supposed to have been caused by’ an accumulation of pus on the brain, or perhaps by’ depression of the internal table. The bone was found denuded of ])eriosteum to the extent of three-cpiarters of .an inch in width by’ two and a half inches in length. Pus to the extent of h.alf an ounce was found in the diploic structure ; also on the surface of the hrain. The patient was comatose, but sensible to the pain of the o])eration, which failed to relieve the sy’injrtoms. He w.as delirious and noisy during the following night ; then became quiet and continued so until the 23d, when death sui)ervened from inttammation and suppuration of the brain and its membranes. The case is I’eported by the operator, Sui'geon J. Bockee, U. S. V. C.VSE. — Private I’hilip R , Co. I, lOth New York Volunteers, was wounded at the battle of F'redericksburg, Virginia, December 13th, 1862, hy a gunshot rii.ssile, which fractured and dej)ressed the left parietal bone, just behnv the tuberosity’. He was .admitted into the Ascension Church Hospital, Washington, on the 17lh, ji.artially’ insensible, but answering when spoken to sharply. The ))Ui)ils were nearly normal, i)ulse 72, ami gradually’ becoming slower and more suggestive of approaching coma. On the 19th, the patient was placed under the influence of chloroform, and Surgeon J. 11. Brinton, U. S. V., assisted by Surgeon J. C. Dorr, U. S. V., and Dr. Brodie of Edinborough, performed the operation of trephining. The depressed fragments were elevated and removed, causing considerable haemorrhage, which gradually ceased after the operation. At seven o’clock P. M., the pulse was 68, tlu’eady’ and .sh.arp ; ])atient semi-conscious and complaining of cold. The next morning the pupils were nearly normal ; pulse 78; breathing natural, but bowels not open. There w.as considerable haemorrhage at noon, which was I’eadily checked. Afterward, coma gradually’ supervened, the ])upils became dilated and insensible to light, and involuntary urinations occurred. He continued to sink rapidly, and died on the morning of December 22d, 1862, in a state of complete coma. The |)athological specimens are Nos. 528, 965, and 966. The former shows a section of the vault of cr.anium, with one disk and seven fragments from the left parietal bone. The two latter are wet pre])arations of the dura mater and the loft cerebral hemisphere containing an abscess. The specimens were contributed by Surgeon J. C. Dorr, U. S. V. Case. — Private William G. Risher, Co. E, 139th Pennsylvania Volunteers, aged 22 y’ears, was wounded in the defences of Washington, July’ 12th, 1864, by a conoidal ball, which fractured the frontal bone three-fourths of an inch to the right of the median line and half an inch anterior to the coronal suture, and lodged. He was admitted to Campbell Hospital on the 13th in a comatose condition, and on the same day Acting Assistant Surgeon E. A. Kemp applied the trephine, and removed the ball and fragments of hone which had been driven two inches into the brain substance. Ice was applied to the head, ])urgatives administered, and abstinence from food rigidly enforced. Death supervened on July 15th, 1864. The case is reported by Surgeon .1. H. Baxter, U. S. V. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. Cask. — Sergeant Willard Robeck, Co. G, 5tli Iowa Cavalry, was treated in tlie regimental liosjiital near Fort Donelson, Tennessee, for injury and compression of tbe brain. When and where the injury was veceived cannot be definitely ascertained, but tbe operation of ti'ej'bining was performed. Death occurred April 24tli, 1833. Case. — Private L. Scliumpcrt, Co. F, 20th South Carolina. Shell fracture of the left temporal bone, July 18th, 1803. Trephining August 10th. Death, August 11th, 1863. Autopsy.* Case. — Corporal Charles Stotter, Co. C, 11th Kansas Volunteers, received at the battle of Prairie Grove, Arkansas, December 7th, 1802, a gunshot wound of the head, witli fracture of the jiosterioi' portion of the right ])arietal bone. Ho \vas admitted into the regimental hospital on the following day, where trephining was resorted to. Fungous tecrescences formed ni)on the brain a few days later,, and were removed by caustic a])j)hcations. About the twelfth day after the operation, an abscess was developed in the cerebral substance, and death resulted therefrom December 27th, 1802. The case is reported hy Surgeon George W. Hogeboom, 11th Kansas Volunteers. Case. — Private John Sperber, Co. A, OCth New York Volunteers, aged 43 years, was wounded at the battle of Antietam, Marj'land, September 17th, 1862, by a conoidal musket ball, which fractured and depressed the cranium at the junction of the occipital and parietal bones, driving fragments into the brain substance. Ho was admitted to the field hospital, and cold water dressings were applied. Convulsions and insensibility ensued, whereupon Surgeon C. S. Wood tre|jhined and elevated tin; depressed portion, removing all detached fragments of bone. The lodgment of the missile was not ascertained. Consciousnt'ss was restored by the operation, but convulsions recurred, and the patient died on September 23d, 1802. The case is reported by tlie operator. Surgeon C. S. Wood, 66th New York Volunteers. Case. — Private G. W. Summers, Co. F, 11th New Hampshire Volunteers, was wounded near Petersburg, Virginia, July 22d, 1864, by a shell, which fractured the cranium. He was immediately conveyed to the field hospital of the 2d division, Nintli Corps, where the operation of trephining was performed. He was thence sent to Washington, but death supervened on the 30th wliile on the way. The case is reported by Surgeon Theodore S. Christ, 45th Pennsylvania Volunteers. Case. — Sergeant Eugene 13. Stinson, Co. F, 12th Maine Volunteers, aged 28 yeans, was wounded at Winchester, Virginia, September 19th, 1864, by a conoidal ball, which fractured the frontal bone, about half an inch to the left of the median line, and two inches below the coronal suture. He was admitted to the hos])ital of the 1st division, Nineteentli Corps, on the same day; on September 22d sent to the depot field hospital at Winchester, and on the 25th transferred, via Sandy Hook, Maryland, to the Mower Hospital, Philadelphia. In the course of ten days after admission, premonitory head syin])toms of a violent and unmistakable character exhibited themselves, and the patient became rapidly comatose. On October 12th he was chloroformed. Acting Assistant Surgeon W. P. Moon then made a crucial incision through the integument, trephined the frontal bone at the margin of fracture, to the left of the median line, and one inch below the coronal suture, elevated the depressed bone, and removed a section of the outer, and seven spicula; of the inner table. The internal table was fractured and driven down u])on the membranes, while the outer table was only slightly indented, neitlier fissure nor fracture being perceptible. The patient reacted promptly, and continued to improve for three days. The pulse became fuller and more regular, the coma lessened, and the cerebral symptoms subsided. On the fourth day he had a chill, com|)lained of pain in the epigastric region, and his respiration became hurried. The next day he began to sink rapidly, coma returned, and death followed on October 18th, 1804. A. post- mortem examination revealed an abscess in the left hemisphere, at the point of injuiy. The membranes were much congested. The case is reported by Acting Assistant Surgeon W. P. Moon. Case. — Private H. L. Smith, Co. 13, 1st Arkansas Regiment, received, at the battle of Shiloh, Tennessee, Aj)ril 0th, 1802, a fracture of the occipital bone. He was, on April 17th, admitted into Hospital No. 6, Louisville, Kentucky, the wound being in a bad condition. On the 22d chloroform was administered, and Assistant Surgeon Benjamin Howard, U. S. A., ai)])lied the trephine, and removed some loose bone. Partial coma supervened and continued until death, which occurred on April 25th, 1802. Case. — Lieutenant William D. Sprouse, Co. B, 40th Illinois Volunteers, was wounded near Atlanta, Georgia, August 1.5th, 1864, by a conoidal ball, which fractured the left parietal. He was at once admitted to hospital 4th division. Fifteenth Corp.s, where, six hours after the reception of injury. Assistant Surgeon William Graham, 4(!th Illinois Volunteers, trephined the skull; the patient being under the influence of chloroform. Ho was on the same day sent to the hosjiital of the Fifteenth Corps, at Marietta, and died on August 23d, 1634. Case. — Private Isaac Souls, Co. H, 23d South Carolina Regiment, aged 19 years, received, on August 30th, 1862, a gunshot fracture of the frontal bone, near the anterior fontanelle, and directly on the median line, lie was admitted into the Confederate hospital at Charlottesville, Virginia, and on September 5th, the trephine was applied to the right of the median line, to avoid the longitudinal sinus. Owing to the existence of a lateral deviation, the sinus was exposed u])on removing the disk of bone, but not injured. One week after the operation, severe chills set in, followed by fever ; then double ])neumonia made its appearance, with symptoms of pyrnmia, and sixteen or seventeen days after the operation, the patient died suddenly during a fit of coughing, from rupture of the longitudinal sinus, and profuse hasmorrhage. A post-mortem examination revealed ulceration of the coats of the siuiis, with small spiculae of bone resting upon it. The case is re|)orted by Assistant Surgeon B. W. Allen, P. A. C. S. Ca.se. — Private William Thompson, Co. E, 12th Illinois Infantiy, was wounded at Allatoona, Georgia, October 5th, 1804, by a conoidal ball, which fractured the external table of the right ])arietal bone. He was on the same day admitted to the hospital of the 4th division. Fifteenth Corps, .and on the 9th sent to the general hos])ital at Rome, Georgia. On the 14th, violent convulsions occurred; the patient was placed under the influence of chloroform and ether, when Surgeon J. H. Grove, U. S. V., applied the trephine, and removed fragments of necrosed bone, giving exit to a <]uantity of |>us which had formed beneath the bone. Consciousness returned, and the convulsions subsided soon after the operation, but returned on the following athological specimen is No. 2375. Sect. I, A. JI. IM., and consists of a disk and three small fragments of bone. The specimen and history were contributed by Surgeon 1). W. Rliss, U. S. V. The man was discharged on November 20th, 1865, and pensioned. On A])ril 10th, 1867, Pension Examiner Thomas B. Reed reported that there was a large depression at the seat of injury which was very sensitive. The patient said that he lost seventeen ])ieces of bone and could not bear the heat of the sun, and suffered from headache, dizziness, impaired memory, and defective eyesight, and was gradually growing worse. C.vSE. — Private E. llemvg, Co. E, 38th Georgia Regiment, was wounded at the battle of Antietam, Maryland, September 17th, 1862, by a conoidal ball, which struck in the middle of the right ])arietal hone, carrying away a consiilerable portion ot both tables. The wound was hurriedly dressed upon the held, after which he was sent to hospital, where his wound soon closed without having undergone any further examination for sjiicula; or depressed portions of bone. Soon after the wound had healed, he was attacked with ej)ilej)tic hts, which coutimusl at uncertain intervals until the 18th of May, 1864, when he was again admitted to a Confederate hospital. Ujion examination of the cicatri.x, a very marked depression was found, and an elastic, yielding sense of touch beneath it. The epilepsy continuing, and the attacks becoming more frequent, it was decided to operate. Acting Assistant Surgeon R. R. Ritchie, 1’. A. C. S., administered chloroform and made a T incision, the first j)art lying parallel with the sagittal suture, and the second striking it at about its ujiiter third, over the cicatrix and above the point of fluctuation. The scalp was found adhering to the skidl, and abnormal in structure and thickness. The opening through the inner and outer table was covered with a firm cartilaginous layer, on removing which considerable hmmorrhage from within took place, which was, however, promptly controlled by the application of a heated needle to the orifice of the vessel. The trei)hine was first applied above the opening toward the corono-sagittal suture; after the removal of which portion, it being evident that the de|)ression e,xtended farther, and the loss of substance around the open skull, near the point of fluctuation, i)recluding the idea of elevating the depressed bone, the trephine was again applied, ])osteriorly, and somewhat beneath the first jdace, at about one inch distance, and the hone having been removed, the edges of the skull between tho first and second openings, and between either and the point where both tables had been destroyed b}'^ the missile, were taken away by means of Hey’s saw, leaving a truncated opening of about half an inch square. Immediately beneath this was disclosed a decided convexity and fluctuation, combined with a peculiar discoloration of the dura mater. This memliraue was carefully divided, revealing the ball resting, point downward, on the brain, and giving exit to about four ounces of a yellowish serous fluid. All pressure being removed, and the How of blood arrested, the wound was closed by interrupted sutures, and cold water dre.ssings applied. Patient reacted Well from the effects of the chloroform, and did unusually well until the morning of the fifth day, when he had another convulsion, which w’as attributed to the accidental disturbance of the bandage, and did not recur. The wound healed by first intention, and there was every probability of a com])lete recovery. Tho case is reported by Sui'geon B. Roemer, P. A. C. S. Case. — Private Charles L , Co. B, 55th New York Volunteers, aged 30 years, was wounded at the battle of Malvern Hill, Virginia, July let, 1862, by a conoidal ball, which struck the right frontal bone about an inch above the right suiierciliary ridge, and lodged. He was conveyed to Washington, and admitted into the Judiciary Square Hos])ital on the 4th. On the 10th, he complained of constant headache and nausea ; the right eye was injected, but the tongue, jnilse, and bowels were normal. A ])ortion of the frontal bone was depressed, and the pulsations of the brain could be seen fluctuating u]) and down the fissures of the fracture. It being feared that the depressed ])ortions might irritate the dura mater and give rise to inflammation, and in view also of the constant headache, the skull was trephined on the 11th by Acting Assistant Surgeon David W. Cheever, and two large j)ieces and some splinters of depressed bone were removed. At one })oint the dura mater had a de])ressiou as if made hy the passage of the hall ; otherwise it looked uninflamed and healthy, but there was some effusion of blood. Water dressings and low diet were ordered. On the second day after the operation, pain was felt as the head was moved aborit, but no fever existed. There was considerable discharge of laudable jms. The brain was still seen pulsating on the ITdli, but not so plainly as before. On the 20th, his condition was every way favorable; the jud.se quiet, tongue clean, skin cool, a|)petite good, no pain in head, the wound closing, and granulations seen over the dura mater. He recovered, and was discharged from the service January 4th, 1863. A communication from the Commissioner of Pensions, dated January 2d, 1868, .states that L is a pensioner, and that his disability is rated at one-half and temporary. The ])athological specimen is No. 261, Sect. I, A. M. M. The disk and fragments of cranium removed by tho trephine embrace one-fourth square inch in surface. The siu'cimen and history were contributed by Acting Assistant Surgi‘on U. W. Cheever. I’ension Examiner P. Stewart, of Peekskill, rej)orts that the patient suffers from giddiness and vertigo. Ca.se. — Priv.'ite G. W. McIntosh, Co. H, 40th Indiana Volunteers, aged 31 years, w’as wounded at the battle of Dallas, Georgia, .June 4th, 1864, by a conoidal musket ball, which fractured the frontal bone just above the left eminence. He was on the same day admitted to the hospital of the 2d division. Fourth Corps; thence transfei'red to tlu^ Cuudjerland Hos])ital, Nashville; and on the 29th sent to the Totten Hosj)ital, Louisville, Kentucky. His constitutional condition was excellent. Only simide dressings were applied to the wound, but small pieces of bone were dischaiged from time to time. The patient complained of dizziness and headaclu-, and was strongly impressed with the idea that the ball remained in tbe wound, of which there seemctic fits supervened in September, 1863, and graduall^^ became more freq-aent and intense until March, 1864, when he was again admitted to a hospital. At that time the cicati-ix was four and a half inches in length, pointing obliquely backward under an angle of 60° with the coronal suture, deepening and widening in its centre, and jiresenting a dejiression of three-eighths of an inch in depth; tin! scalj> here is )'adiated, as if the covering had assumed the abnormal condition of the bone beneath. The epileptic paroxysms were now comjiosed of a number of successive convulsions. His general condition previous to an attack was marked by dejection of s|)irits, vertigo, and apathy, his bowels habitually costive, ajipetite wanting, urine scanty, pulse CO and feeble, and face pale. Extravasations being sujiposed to exist, it was decided to ajiply the trejihine. Chloroform having been administered. Surgeon D. Eoemer, P. A. C. S., made two incisions in the foi'in of a "T ; one nearly j)arallei with the coronal suture, upon the np|)er margin of the parietal bone, about half an inch from the cicatrix, and uniting with it; the second over the upper third of the cicatrix and behind it. The first measured three and a half inches, and the second four inches. The trephine was ajqflied at the iqiper j)art of the depression. The bone came away with the trephine, and no adhesions of the dura mater existed. Immediately below, and almost in the centre of the opening, lay a violet-colored, circular, and somewhat convex extravasation, covered by tbe dura mater, wliich was divided by a simj)le cut. No haemorrhage occurred from beneath the skull, and three small arteries of the scalj) had been readily controlled without ligation. The extravasation being removed, the wound was closed with adhesive straps, and cold water dressings and a cross-bandage applied. The ])atient reacted well from the effects of the chloroform, and walked about in his quarters on the second day. The wound healed by first intention. Two weeks after the (q)eration he expressed himself as free from any unpleasant feelings. The condition of his bowels became healthy, his general aspect cheeiful, and the jirognosis was highly I'avorable to complete recovery. The case is i-ecorded by the operator, .Surgeon 13. Eoemer, P. A. C. S. Case. — Corporal Eredeiick Weber, Co. E, 116th New York Volunteers, aged 22 years, was struck at the battle of Cedar Creek, Vii-giina, October lOth, 1864, upon the upjier portion of the left side of the forehead by a conoidal musket ball, which denuded the frontal bone near the coronal suture for a considerable space, jn-odneing, as was stated by the attending physician, an hulentation at the place of imjungement, but no apparent fracture. The man was insensible for some time, though ]ierfect reaction at length ensued. He was on the following day admitted to the depot field hospital; on October 22d, transferred to the hospital at York, Pennsylvania; and on November 7th furloughed to visit his friends in Buffalo, New York. On his arrival at that place he was attacked with pneumonia, and came under tlie care of Acting Assistant Surgeon S. W. Wefmore. Upon examination of the wound of the head, which was at this time discharging freely, a fracture in the external table was discovered; a jiiece measuring one and a half inches by two and one-fourth inches being loose, though not displaced. Having recovered from pneumonia, he w.as, on December 1st, admitted into the hospital of the city. On December 17th, Acting Assistant .Surgeon ,1. F. Miner removed the irregvdar-shajied loose jiiece of bone of the external table, as well as fragments of the internal jflate. The wound afterward healed kindly though slowly, and the man was discharged from seiA’ice on June 7th, 1865, enjoying then good health, with the exceiUion of an occasional pain in the region of the wound. In July, 1868, he was a pensioner at .|8 per month, his disability being total and ])ermanent. The case is i'e])orted by Acting Assistant Surgeon S. W. Wetmore. Sub- sequently Dr. II. N. Loomis of Buffido reported that this jiatieiit had a painful cicatrix depressed half an inch, and suffered from defective vision and vertigo, with chronic irrit.ability of the brain, which unfitted him for any kind of labor. Thereupon his pension was increased to .$20 per month. ■An account of tliis case will be fuiuid in tlio Am. Jour. Med. Sci.. 1871, Vol. LXII, N. S., p. 385. TEEPIIINIKG AFTER GUNSHOT FKACTUEES OF THE SKULL. 283 CiVSK. — Private Philip A. V.'- Co. A, COtli Pennsvlvania Volunteers, aged £1 years, was wounded at Petersburg V'irgiiiia, July bOth, 16G4, by a conoidal ball, wliicli imbedded itself in the iutegunieiit and niuecles of the left side of the bead, fracturing and depressing a })ortion of the skull a little above and to the left of the occipital ])rotuberauce. The missile was removed by the hand. He was somewhat stunned by the blow, but arose and walJeed to the hosjdtal ot the 3d division. Ninth Corps, when he became unconscious and remained so for eighteen hours. On the following day he returned to his regiment, not knowing that his injury was severe, but he was returned to the ho.spital, whei-e he remaim'd for one week. He suflered severe headache and was unable to see or hear well. On August 11th, he was admitted into the Soldier’s Rest, branch of 1st Hivisiou Hospital, x\lexandria, Virginia.- He seemed to improve for two days, then grew worse, complaining of pain in the frontal .-egiou of the head, especially over the left orbital ridge. On the IGth, ho became uncomseious for about two hours. It being deemed advisable to remove the depressed portion of the bone, ether was administered, and Assistant Surgeon Theodore Artaud, U. S. V., made a crucial incision, half an inch in length, directly over the injurj', and dissected up the oceipito-frontalis muscle, revealing an indentation, half an inch in length, making a very regular cup-sliaped deiiression, three-fourths of an inch in diameter, -with a slight lissure around its edge and an irregular one across its centre. The trephine was applied so as to jiartially cov(‘r one side of the depression, and a portion of the skull was removed. The depressed bone was then i-emoved by the elevato”, exposing the dura mater, whieh was found to be healthy. A circular tent was apidied over the exposed portion of brain, the wound dressed with cold water dressings, and morphia given to (juiet the patient. The following day ho was able to sit up, and by the £0th could walk about. On the 2Gth, ho was seized with violent signs of compression, but was soon relieved by sinapisms to the neck, abdomen, and extremities. Croton oil was given, and afterward the wound, wliich had nearly healed, was enlarged and kept open with tents for three days, with but slight inconvenience to the ])atient. He had slight headache on the morning of September 1st, but his general condition was good and inijiroving. He ate and slept well, and by the 22d, thcAvoimd had entirely closed. He occasionally complained of slight headache, and was, to all appearances, cured. He was transfiuTcd to Slough Barracks, branch of3d Division Hospital, on Oetoberbth, remaining until May 10th, 18G5, when he was sent to the Augur Hospital, Alexandria, and thence, on the 20th, transferred to the McClellan Hospital, Philadelphia. He was discharged from the service on July Gth, 1865. A communication from the Commis- sioner of Pensions, dated July, 1868, states that W. is a ))ensioner at $8 per month, liis disability being rated total and temporary. The specimen Avas contributed, with an history, by the operatoi-, Assistant Surgeon Theodore Ai-taud, U. S. V. Fig. 1'12. — Disk aeU fra^rinents romevril after a I'ractm-c liy a sj.-ent ball. Sjicc. 5U42, Sect. 1. A. JI. JI. f. Case.— C aptain Alvin M. W , Co. K, 17th Ncav York Volunteers, Avas Avounded at the battle of Frodovieksburg, Virginia, December 13tli, 1832, by a musket ball, Avhich fractui-ed the left parietid lione near the eminence. He Avalked Avith some assistance to the ho9|ntal of the Third Corps, a distance of more than a mile. His voice became thick and had an umiatural hesitancy and slowness. The middle and ring finger of the right hand Avere jiaralj-zed, hut the motion and sensibility in th(! iirst and fourth fingers Avere oidy slightly impaired. His mental faculties Avere clear. He comjdained of a slight headache and his pulse was sIoav and full. The trephine Avas applied by Assistant Surgeon LcAvis Tice, 17th Ncav York Volunteers, and a disk of bone and several fragments Avere removed, one of which Avas three-fourths of an inch in diameter. The edges of the Avound Avere approxunated by adhesive strips, and cold Avater dressings Avere ^pplied. During the opia-ation, blood lloAved profusely from the jierforation. One large fragment of bone, evidently fi-om the inner table, lay exactly beneath, but Avas too large to be extracted from the orifice. The dura mater Avas found to be uninjured. The poAA-er of articulation returned immediately after the operation, and the numbness of the fingers hecame less marked. On Januai-y 2d, 1863, the paralysis of the fingers had entirely disappeared and the AVound Avas healing hy granulation. The jiatientAvas mustered outAvith Ids regiment on June 2d, 18G3. The pathological specimen is No. 4049, Sect. I, A. M. M., and Avas contiibuted by the operator. The Conmiissioner of Pensions reports that this officer Avas jiensioned at $20 per month. A musket ball entered the upper portion of the right parietal bone; bones liave been remoA'ed so that an irregular opening exists of the size of a silver dollar. I’ension Examiner T. C. Pitt states that Ids right hand and tongue Avere partially jiaralyzed. Exercise jiroduces violent throhbing at the wound and at a point opposite on the back of the head. His general health is very poor, probably owing to the constant irritation about the brain. Fig. 143. — Disk and fragment from a gunshot depressed fracture of the leit parietal. jS 2 )cc. 4041), Sect. I, A. M. M. Case. — Private Joseph Wolf, Co. F, 7th New York Heavy Artillery, aged 22 year.s, was wounded on April 3d, 18G5, Ix^oro Petersburg, ATrgiida, by a conoidal ball, which entered the scalp near the ])Osterior suiierior angle of the right jiarietal bone, and glanced upAvard, denuding the bone of periosteum for a space one inch in circumference. He Avas on the same d.ay admitted to the hosidtal of the 1st division. Second Corp.s, and thence conveyed to Washington, where he entered the Armory Square Hospital on the 12th, Avith comjiletc paralysis of the left arm and leg. He Avas slightly comatose, but could easily be aroused, and ansAvered questions intelligently; the pupils Avere contracted. An examina- tion rcA’calcd a fissure extending beyond the denuded portion, through Avhich pus shnvly exuded, but no depression was observed. Ether Avas administered on the 14th, and Surgeon D. W. Bli.ss, U. S. V., applied the trepliine. U])on removing the button of bone, a similar fissure through the internal table Avas discovered. The dura mater protruded through the opening, and, upon punctming the membrane, about three ounces of sero-sangunieous fluid Fig. 144. — Disk and fra^^monts re- moved after gunshot fracture (.f tho right parietal. Sjjcc, 4Ll*5, tScct. 1 , A. M. M. WOUNDS AND INJUEIES OF THE HEAD, ;:!84 cscn))«l. Tlic o])or:;ti()n ."fTorik'd no immcdir.te roliof to flie paticMit, but at tho end of r.ix lionrs lie could move Ida band and foot, and on the following day could raise bis bead. On the 20th, the wound was granulating finely, and the i^atient doing well, lie could move bis leg and ann freely on the 2Gth, and was able to stand upon bis feet. On May 1st tbe paralysis bad almost disa]ipcared, and tbe wound was entirely covci-ed with granulations. Two days later a small circle of necrosed bone was removed from tbe external table. Tbe jiaticnt was now able to walk about tbe ward, and on tbe 2Gtb, was transferred to tbe Wbiteball Hosiutal, near Dristol, Pennsylvania, wbcnce be was discharged from tbe service on June 20tb, ISGb. Ills claim for pension was “pending” December 7tb, 1871. Tbe specimen is a disk of bone with a serrated fragment of tbe inner table-of the right jiarietal bone, and is represented in tbe wood-cut. Tbe disk is one inch in difnneter, and is traversed by tbe line of fracture. Tbe specimen was contributed by tbe operator, Surgeon D. W. Bliss, U. S. V. Case. — Private George A. Shaffer, Co. D, IfOtb Pennsylvania Volunteers, aged 19 years, was wounded at P''ive Forks, Virginia, April 1st, 18G5, by a conoidal ball, wbicb fractured the parietal bones at tbe junction of the coronal and the sagittal sutures, tbe fracture extending back about three inches over the sagittal suture. He was on tbe next day admitted to tbe bos])ital of tbe Fifth Corps, and on April 4tb sent to tbe Lincoln Hospital at Washington. There was but slight evidence of compression, but on April (itb, be complained of pain in the bead; the pupils became dilated, and coma supervened. He was jilnccd under tbe influence of ether. Surgeon J. C. McKee, U. S. A., then made a crucial incision at right angles to the parietal suture and removed the fragments, revealing tbe dura mater intact. The patient was kept quiet in a recumbent position, cold ajiplications were made to the head, and low diet ordered. Ho recovered, and was discharged from the service on a surgeon’s certificate of disability on June 24tb, 1865. See Photographs of Surgical Cases, Vol. HI, page 10. He is a pensioner. Tbe case is reiiortod by Surgeon J. C. McKee, U. S. A. Tlie following remarkaLlc instances of patients recovering sufficiently to resume tlicir military duties are reported ; Case. — Lieutenant H. S. Robinson, Co. G, 3Gth Massachusetts Volunteers, received, at Blue Springs, Tennessee, October 12tb, 1803, a gunshot depressed fracture of tbe right jiarietal bone. He was admitted into the hospital at Knoxville, Tennessee, tbe same day, where a portion of bone was removed by Hey’s saw. He recovered, was returned to duty on December 2Gtb, 1803, and was discharged from tbe service on July 7tb, 1804. He was a pensioner in 1807. Active exertion caused headache and a feeling of pressui’e on the brain. Case. — Corporal Pbincas Bird, Co. C, lOOtb Pennsylvania Volunteers, aged 21 years, was wounded at tbe siege of Knoxville, Tennessee, November 20tb, 1833, by a conoidal ball, which fissured tbe left parietal bone without depression. Ho was conveyed to Hospital No. 5, when', on November 25tb, tbe bone was trephined. Hewas furloughed on February 17tli, 1804. and shortly afterwards returned to his regiment. On October 1st, he was admitted into tho general hospital at Pittsburgh, Pennsylvania, and, on the 20th, again returned to duty. lie does not appear to have been an applicant for pension. » Case. — Asa D. Broody, bugler of the 7th Indiana Battery, aged 20 years, was wounded at the battle of Kenesaw ^Mountain, Georgia, June 22d, 1834, by a conoidal musket ball, which fractured and depressed the right temporal bone. Ho was at once admitted to the 3d division. Fourteenth Corps, hospital, and thence sent to Chattanooga, Tennessee, where ho arrived on the 29th of the month; two days subsequently, however, he was transferred to Hospital No. 2, at Nashville. Ho recovered, was furloughed, and finally returned to duty on September 19th, 1834. This soldier was discharged the service December 7th, 1834, and was pensioned. On September 4th, 1863, Pension Examiner J. G. Hendricks reports that the operation of trephining had been peiformed. There was paralysis of the left arm, and the flexor tendons of the fingers were contracted. His disability is rated total and permanent. Case. — Private Robert S. Erwin, Co. B, 86th Illinois Volunteers, aged 32 years, was wounded at Atlanta, Georgia, July 20tb, 1864, by a conoidal ball, which fractured the superior portion of the fronfal bone, and lodged in the cranium. A portion of the fractured bone was driven into the substance of the brain. lie was, on tlie same day, admitted to tho field hospital of tho 2d division. Fourteenth Corps; conveyed, on July 22d, to No. 2, Chattanooga, Tennessee, and thence sent to Nashville, where be entered Hospital No. 1, on August 1st. On the 3d, Acting Assistant Surgeon John Grant made a triangular incision, two and a half inches in length, applied tbe trephine, and removed the fractured bone. Tho soft parts were swollen, and the dura mater lacerated. There was a free discharge of pus, of an unhealthy character, but the patient’s constitutional condition was good. Simple dressings were applied to the wound. Erwin was transferred on December 12th, entered Jefferson Hospital, Jefferson- ville, Indiana, on the 13th, and was returned to duty on December 21st, 1834. He was again admitted into Jefferson Banneks Hospital, St. Louis, on January 10th, 1835; on the 14th of April sent to Small-pox Hospital; and for the second time returned to duty on June 3d, 1865. This soldier was discharged the service August IGth, 1835, and afterwards pensioned. On Januaiy 19th, 1870, Pension Examiner I. H. Reeder reports that the patient had been subject to frequent attacks of epilepsy since he was wounded, which, within the last year had so increased in frequency and violence as to totally disqualify him for any kind of business or habor. He rates his disability total and permanent. Case. — Private Win. H. Freshwater, Co. G, 45th Ohio Volunteers, aged 18 years, was wounded atRcsaca, Georgia, May 14th, 1864, by a conoidal musket ball, which fractured the left jiarietal bone. He was admittial to the hospital of tho Twenty-third Corps on the same day. The trephine was applied and all the fragments of bone were carefully removed. He was sent to the field hospital at Bridgeport, Alabama, on the 21st ; transferred to Nashville on tho 23d; to Clay Hospital, Louisville, on the 27th ; to Dennison Hospital near Cincinnati, on June 20th; and thence to Seminary Hospital, Columbus, Ohio, on July 1st. He recovered, was furloughed on July 7th, I’eturned on August 8th, and was sent to his regiment for duty on August 11th, 1864. He was discharged June 12th, 1835, and pensioned. His disability is rated one-half and temporary. TREPIIINIKG AFTER GUNSHOT FRACTURES OF THE SKULL. 285 C.\SE. — Private Edward Gordon, Co. 11, Gth New York Cavalry, was wounded while on picket near Yorktown, Virginia, Se]nenibcr 18th, 1833, hy a conoidal ball which fractured and depressed the left parietal hone near the anterior inferior angle. He was admitted to the Nelson Hospital, being unable to speak, j-et able to walk, and scemingl}' conscious. The trephine was applied, a button of bone removed, and the depressed fragment elevated. While lifting the depressed bone, the left side of his face was subject to violent convulsions, which ceased as soon as the fragment had been removed. A pretty free hmmorrhagefrom the middle meningeal artery ceased spontaneously, apparently from pressure of the brain. The patient recovered rapidly and was returned to duty on December 10th, 1862. He is not a pensioner. Case. — Private William Hines, Co. A, 20th Wisconsin Volunteers, was wounded at Prairie Grove, Arkansas, December 7th, 1882, by a conoidal ball, which inflicted a slight scalp wound midway between the anterior and posterior fontanelles, three- fourths of an inch to the left of the sagittal suture, and slightly indented the external table. The injury apparently caused no serious inconvenience, as no record of the case can be found until August 27th, 1863, when the man was admitted to the hospital at Keoknk, Iowa, suffering from typhoid fever. He was discharged from service on November 12th, 1863. It seems that he afterward re-enlisted in Co. D, 2d Wisconsin Cavalry, and served until January 2d, 1865, when he was admitted to the Adains Hospital, Memphis, Tennessee, on account of the injury received at Pi’airie Grove. The state of the patient was now- approaching to idiocy. Involuntary movement of the extremities had existed more or less since the reception of the injury, and the patient complained of intense pain in the head, which was greatly aggravated when exposed to the solar rays. The scalp wound had healed, and an indentation of the skull could easily be detected, sufficient in size to receive one-half of a split pea. Cfn the fifth day after admission, he was placed under the influence of chloroform, when Assistant Surgeon J. M. Study, U. S. V., made a semi-lunar incision three inches in length, reflected the scalp over the seat of injury, and placing the centre pin of the trephine in the indentation, sawed through the skull. After the operation the patient’s progress was rapid. The treatment consisted of cold water dressings for thirty-six hours, when erysipelas set in, and tepid water dressings were substituted. By the fifth day the erysipelas had entirely subsided. The wound suppurated freely, the margin began to heal rapidly, and by January 18th the jiatient was going about the ward, and expressed himself as feeling well and free from all the head symptoms which had existed prior to the operation. On February 12th, 1835, he was returned to duty entirely recovered. The case is reported by the operator. This man was discharged the service November 15th, 1835, and pensioned. On September 16th, 1837, Pension Examiner W. A. Anderson reports that the patient suffers great nervous disability, which is increased upon the least excitement. He is also blind in the right eye, the result of a kick by a mule at Vicksburg, Mississippi, on October 23d, 1864, which, in addition to his previous injury, unfits him for any occupation. His disability is rated total and permanent. Case. — Private John Jastram, Co. B, 39th New Jersey Volunteers, aged 18 years, was wounded while on picket on December 4th, 1864, by a conoidal ball, which fractured the occipital bone. He was admitted on the same day to the field hospital of 2d division, Ninth Corps, where Surgeon L. W. Bliss, 51st New York Volunteers, trephined the skull. On the 7th, he was sent to City Point, Virginia, where he remained in the depot field hospital of the Ninth Corps until the 20th, when he was transferred to the McKim’s Mansion Hospital, Baltimore, Maryland. On January 9th, 1865, he was sent to York, Pennsyl- vania, where he remained until April 17th, 1865, when he was returned to duty. Tliis soldier was discharged the service June 20th, 1835. On December 14th, 1833, Pension Examiner A. W. Woodhull repoi-ts that the man complained of much pain in the wound. Upon a change of weather this was accompanied by dizziness and noises in the head, which prevented him from pursuing his occupation. He rates his disability one-half and permanent. Case. — Private Riley Jump, Co. D, 11th Missouri Volunteers, aged 20 years, was wounded at Tupelo, Mississippi, July 14th, 1864, hy a buckshot, which fractured the left parietal bone and lodged between the tables. He was admitted to the hospital of the 3d division. Sixteenth Corps, and thence conveyed to Memphis, Tennessee, where he entered the Adams Hospital on July 21st. On the following day severe and fi-cquent convulsions occurred. Acting Assistant Surgeon S. S. Jessup administered chloroform, applied the trephine, and removed the buckshot and the depressed bone. Several convulsions occurred after the operation, but were easily controlled by chloroform, and ceased entirely on the fourth day. Stimulants and full diet were ordered, the wound healed readily, and on January 4th, 1835, the patient was returned to duty. The case is reported hy Surgeon J. G. Keenon, U. S. V. He is not a pensioner. Case. — Private A. P. Lowry, Co. I, 6th Iowa Volunteers, aged 19 years, was wounded in a skirmish on the Big Black River, Mississippi, July 6th, 1833, hy a conoidal ball, which struck at a point two inches from and directly above the right e.ar, fractured the skull, and emerged two inches above and behind the wound of entrance. He was treated in the regimental hospital, where, on July 21st, Assistant Surgeon William S. Lambert, Gth Iowa Volunteers, trephined the skull and removed a large piece of bone which was pressing upon the brain. He experienced immediate relief after the operation. On August 2d, he was admitted to St. Mark’s Hospital, Paducah, Kentucky, and, August 3d, sent to Mound City, Illinois. He stated that the first fifteen days after injury the wound was dressed with poultices, and that he was able to walk about until July 10th, when the wound became greatly inflamed. On admission to Mound City Hospital the wound had almost healed, and his health and appetite were good. He was furloughed on September 17th, 1833, and returned to duty December 2d, 1863. He was discharg(!d July 16th, 1864, and pensioned. Pension Examiner Edward Whinery reports that the disability is total and permanent, but that the degree may become less. Case. — Private Reuben Ramsay, Co. 11, 93d Pennsylvania Volunteers, aged 21 years, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, which fractured and depressed the left parietal bone to the extent of a ten-cent piece, about one inch above and .one and a half inches anterior to ear. On the 9th, he was admitted into Hafewood Hospital, Washington, where Acting Assistant Surgeon O. D. Brooks ajiplied the trephine, and removed the dejjresscd jxirtions of bone. Cold water dressings were applied to the wound, and by June 22d he had so far recovered as to be able to go home on furlough. He was returned to duty on August 26th, 1863, entirely recovered. He is not a pensioner. The case is l eported by the operator. Acting Assistant Surgeon G. 1). Brooks. 286 WOUNDS AND INJURIES OF THE HEAD, CaSIC. — Private Janit's 15. Sawyer, Co. G, 27th Micliigaii Volunteers, aged 25 years, was wonnded in an engagement near Petersburg, Virginia. Ctetober 27th, 1864, hy a musket hull, which entered the frontal sinus above the left eye. He was admitted into the field hos])ital of the dd division. Ninth Cor])s, where the operation of trephining was i)erformed hy Surgeon W. B. Fox, 8 th Michigan Volunteers. He was suh, equently tramsferred to the hospital of the Ninth Corps at City Point, and thence, on the 29th, to Washington, entering Harewood Hospital on the 31st. He recoveri'd, and was returned to duty on February 10th, 1865. He is not recorded as a pensioner. C.\SK. — Private Robert W. Thompson, Co. D, 99th Pennsylvania Volunteers; aged 18 years, was wounded at the battle of the Wilderness, Virginia, May 5th, 1864, hy a conoidal ball, which fractured and de])ressod the upper part of the occipital bone, and lodged. He was conveyed to Washington, and entered .Judiciary Square Hosj)ital on the 11th. On the following day he was placed under the induence of ether, and Assistant Surgeon Alexander Ingram, U. S. A., trephined the sknll, and removed the depressed jxu'tion of bone, beneath which the hall and a large firm clot were fonnd. A piece of bone one inch long and half an inch wide, had been driven in upon the dura mater. The patient’s constitutional condition was excellent. On the 14th, the head and face were attacked by erysipelas, which caused swelling and conqiletely closed the eyes. By the 19th, erysipelas had entirely disap])eared, and the patient was nearly well. On the 27th of June, he was transferred to the Satterlee Hospital, I’hiladelphia, and on the 31st j)laced on duty as nurse; his wound being nearly healed. On November 28th, 1864, ho was returned to duty. He is not a pensioner. Cask. — Sergeant Major George W. Wadsworth, 19th Maine Volunteers, aged 22 years, received, at the battle of Gettys- burg, I’eiinsylvania, July 3d, 1863, a depressed gunshot fracture of the cranium. He was admitted to the Seminary Hospital, and on .July 7th sent to Mower Hospital, Philadelphia. At intervals convulsions occurred, supposed to have been caused by depression of internal table. On .July 22d the trephine was applied, and the depressed portion of bone removed by Acting Assistant .Surgeon David McLean. On Sei)tend)er Kith, a piece from the outer table came awa}’. On November 14th the wound had nearly healed, and on December 4th, 1863, the patient was returned to duty. He was promoted to Lieutenant, and discharged June 3Uth, 1863, and jiensioned. I’ension Examiner Israel Putnam reports that the patient must avoid violent exercise and exj)osure to sun, being subject to vertigo. C.v.SK.— Private Charles E. Wood, Co. 1), 14lh New Yoik Cavalry, aged 18 years, received, near Petersburg, Virgini.a, .June 22(1, 1864, a gunshot fracture of the mastoid process of right temporal hone, also wound of right arm and hii). He was admitted to hospital 3d division. Ninth Corp.s, where .Surgeon A. F. Whelan, 1st Michigan Sharpshooter.s, excised spicula; of the tenqioral bone. On .Inly 2d the ])atient was sent to Mount Plea.sant Hospital, Washington, and on July 22d to Mower llosjutal, l’hiladeli)hia, whence ho was returned to duty September 27th, 1864. He is not a pensioner. Four patients recovered sufficiently to be returned to modified duty in the Veteran lleservc Corps : C.v.sK. — Private .John G. Colgan. Co. F, 5th New Jersey Volunteers, aged 22 j-ears, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a ])iece of shell, which struck the upper jiortion of the frontal bone, causing a fracture with dej.ression. He was conveyed to Washington, and on May 9th admitted to Harewood Hosj)ital, where the trephine was apiilied, and the de])ressed portion of hone removed. On May 30th, the wound was doing well, and on June 24th, 1863, the |)atient was transferred to Satterlee Hospital, Philadelphia, where he was assigned to the 2d battalion. Veteran Reserve Corps. This .soldier was discharged the service November 22d, 1865, and pen.sioned. There was a large cicatrix, with depression from loss of the outer table of the osfrontis, near the junction of the coronal and sagittal sutures, with tenderness upon pressure, and the ]iatient conq.lained of vertigo when exposed to the sun, or when undergoing active exercise. His disa- bility is rated one-half, and probably permanent. Ca.se. — Ca])tain .John W. Dempsey, Co. H, 82d New York Volunteers, received at the battle of Bull Run, Virginia, July 21st, 1861, a gunshot fracture of tlie skull. He w.as captured and not released until 1863, reaching Washington July 11th. The skull was trephined. He was furloughed on July 13th, and transferred to the Veteran Reserve Corps July 23d, 1863. Case. — Serge.ant Frank W. Dougliiss, Co. C, 141st Pennsylvania Volunteers, aged 20 years, was wounded at the battle of the Wilderness, Virginia, M.ay 0th, 1864, hy a conoidal ball, which fractured and depressed the frontal bone at the right supra- orbital region. He was conveyed to the hospital of the 3d division. Second Corps, and thence sent to Washington, and admitted to the Campbell Ilosjiital on IMay 13th. Thence ho was sent to the West’s Buildings Hospital, Baltimore, on the 10th, and finally transferred to York, I’enn.sylvania, on May 21st. On .June 1st, Surgeon H. Palmer, U. S. V., trephined the skull .and removed thirty-four pieces of bone. He recovered, and on March 7th, 1865, was transferred to the Veteran Reserve Corps. The case is reported hy the operator. Surgeon H. I’ahner, U. S. V. Douglass was a pensioner in 1809, his disability being regiirded .as three-fourths and jiernianent. The examining surgeon. Dr. Turner, re])orts that both tables had been driven in u|)on the brain ; that the patient sutlers pain, is incapable of much exjiosure to the sun, and is afflicted with loss of memory and sometimes unconsciousness. Case. — I’rivate Collis H. Smith, Co. E, 116th New York Volunteers, .aged 30 3 -ears, was wounded near Fort Darling, Virginia, Mav 10th, 1864, h 3 ' a conoidal hall, which fractured and depressed the frontal bone near the longitudinal sinus. He was conveyed to the field hospit.al of the Eighteenth Coips, and on the 19th sent to the general hospital at Hamj)ton, Virgini.a. On Mav 26th, Acting Assistant Surgeon H. B. White ajqjlied the trephine and removed several pieces of bone, giving exit to a large collection of ])us. The jiatient was in a comatose condition and the external |>arts were softened and much contused. The removal of the boue and consequent discharge of pus, in a manner relieved the coma, but the reaction was very slow. B 3 ' June 3d, the wound was closed and healing finely, and the patient was doing well. On October 15th, he w.as sent to the hosjdtal at TREPinXlNG AFTER GUNSHOT FRACTURES OF THE SKULL. Whitt'liiill, Pennsylvania, and on Jamiaiy 20tli, 1835, he was transferred to the Veteran Reserve Corps. The case is reported by Assistant iSiirgeon Ely McClellan, IT. 8. A. This soldier was discharged the service iSepteniber 4th, 1835, and was afterward jtensioned. On May l'2th, 1830, Pension Examiner George I’age reports a depression at the original seat of injury. The patient sutfered from cephalalgia, with occasional blindness and dizziness, and his memory was somewhat affected. His distibility is rated one-half and permanent. In the six following cases of recovery, after trephining for gunshot injury, the men were exchanged, paroled, or furloughed : Case. — Private Patriclc Lane, was wounded at Irish Bentf, Louisiana, April 14tli, 1863, by a conoidal hall, which fractured and depressed the right parietal bone at its jtosterior superior angle and lodged, carrying with it portions of cap and hair. Simple dressings were applied. F'our days after the recejttion of the injuiy, epilepsy supervened, and Surgeon W. N. Trow'- bridge, '23d Connecticut Volunteers, removed two buttons of bone with the trephine. No further treatment is recorded, hut the report of Surgeon W. N. Trowbridge states that the patient recovered. Case. — Private James H. Itichardson, Co. B, 19th Louisiana Regiment, was wounded at the hatth' of Shiloh, Tennessee, April 7th, 1832, by a round musket hall, whicli caused a depressed fracture of the cranium. He was admitted into Hosj)ital No. 3, Evansville, Indiana, April 18th, 1882, being at the time in a state of general paralysis. The o])eration of trephining was soon afterward performed. The patient improved -slowly, and on August 31st, was enabled to walk. On November 30th, he was transferred to Indianapolis, Indiana, and paroled on November 26th, 186*2, still suffering from paralysis. C.\SE. — Private John Cotton, Co. G, 17th Georgia Regiment, aged 23 years, received at Cedar Run, Virginia, August 9th, 1862, a gunshot fracture of the cranium, near the left parietal jirotuherance. The internal table was injured to a greater extent than the external plate. Ho was admitted into the Confederate hospital at Charlottesville, Virginia. On Sejitember 14th. the trephine was applied, and several pieces of bone removed. The mind was not .affected by the operation, but there was slight paralysis of the right side of the body. Ten days after the operation, erysipelas supervened, but wuis readily subdueil. The patient did well, constantly improving until October 9th, 1882, when he was furloughed. The wound had entirely healed. Case. — Private J. IF. Hambleton, of Lathatn’s Virginia Battery, aged 37 years, received, at Cedar Run, Virginia, August 9th, 1862, a gunshot depressed fracture of the cranium, at the junction of the left temporal with the jiarietal bone. When he was admitted into the Confederate hospital at Charlottesville, Virginia, on August 11th, his mental and physical faculties were unimpaired. On the 24th the trephine was applied, and all fragments of hone were i-emoved. About a week after the oj)erati()u the patient had a slight attack of erysipelas of the scalp, hut soon recovcjred from it. In March, 1865, he had entirely recovered, but was injuriously affected when exposed to the heat of the sun. The case is reported by Assistant Surgeon B. W. Allen, 1*. A. C. S. Case. — Private J F , 9th Louisiana Regiment, was wounded at the battle of Murfi’eesboro’, Tennessee, December 29th and 30th, 186'2, by a shell, which struck over the right parietal hone, causing a contusion without lu'oducing any external wound, but dejwessing nearly one-half of the bone, leaving a cavity of considerable size. When admitted to the Lagrange Hospital his health was very j)Oor; the left side was paralyzed and his intellect obtuse; the extremities were oedematous. The trephine was applied and a button of bone removed, revealing extensive fracture of the internal table, and an osseous tumor of nearly an inch in diameter, whose apex was removed by the tre])hine. The dura mater was in very good condition, though ti’aces of inflammation were evident. A marked improvement manifested itself in a few days. His apjietite improved, the oedema disap]teared, and he was soon able to walk about the ward. Ca.se. — Corporal J. A. Gray, Co. I, 12th Mississippi Regiment, was wounded at the battle of Chancelloi-sville, Virginia, May 3d, 1863, by a fragment of shell, which struck the left parietal bone at the posterior superior angle, deiiressing both tables fully half an inch, lie was conveyed to Washington, and on May 7th admitted to St. Aloysius Hospital. No untoward symptoms occurred until May 9th, when he was attacked by epileptiform convuLsions, with comjdete loss of consciousness. On the following day the trephine was ai)plied, and a button of hone, consisting of the external table only, was removed from the interior edge of the fracture. Ih-agments of the external table were then removed which had been driven backward between the tables beyond the ])oint of fracture, depressing, to a considm-able extent, the inner table, which presented on its exposed surface no fracture or even fissure. It being deemed that the r<'moval of the fragments would permit of the gradual and spontaneous elevation of the inner table, and it being impossible to elevate it at the time without a])]ilying the trejdiine in a new j>osition, it was determined to leave the case without further interference, unless .symptoms of convulsions recurred. Ice was applied, and no untoward symptoms occurred. The inner table partially resumed its natural ))osition, and became covered with new granulations. He was doing well on July 27th, 1863, and was sent to provost marshal's office August 25th, 1863. The following thirty-six cases recovered after trephining for gunshot fractures of the skull, with different degrees of physical disahility, and were discharged from service: Ca.se. — Private .lolin II. Ballai’d, Co. B, 42d Indiana Volunteers, aged 23 y(‘ars, was wounded at Dallas, Georgia, May 2.5th, 1864, by a conoidal ball, which fractured the left frontal and temporal bones. He was admitted to the hospital of tlie 1st division, F'ourteenth Corps, on 5Lay '27th, where the skull was trej)hiued, and thr(?e inches of bone were removed. He was sent to the field hospital, Chattanooga, Tennessee, on .June 2d; transferred to the Cumberland Hosj)ital, Nashville, on the 3d; and thence furloughed on July 30th, and ordered to report to the medical director at the ex])iration of his leave. On September 13th he was admitted to general hospital, Evansville, Indiana, and discharged from 8ervic(! on F'ebruary 13th, 1865, by reason of loss of vision of left eye. Th(' case is re])orted by Surgeon G. Perin, U. S. A. Ballard was pensioned. On l'’ebruary '23d, 1885 28S WOUNDS AND INJUDJES OF THE HEAD, IV'iisiou Exjuiiiiicr 1!. J. D;:v. of Evansville, Indiana, reports tliat tlic wound lias several times reopened, and that a piece of load was removed. The man sull'ers from pain in head and dizziness. Case. — Coi'pcral W. \Y. Liarlow, Co. 15, 1st Maine Cavalry, aged 23 years, was wounded at Dinwiddle Court-house, Virginia, March 31st, 18G5, by a eonoidal musket ball, which caused a compound fracture of outer table of the os frontis, left side, with comp.ound comminution of inner table. He was admitted into the Cavalry Corps Hospital at City Point, Virginia, oil the following day, and transferred on April 4lh to Wa.shington, per hospital steamer Thomas Powell, entering Mount Pleasant Hospital on the same day. The case progressed favorably until the morning of the 7th, when the patient had convulsions, followed by intense headache. The fractured portion of the outer table was then i-emovcd. On the following day ether and chloroform were administered, anti Assistant Surgeon H. Allen, U. S. A., removed two largo pieces of the inner table through the opening which had been enlarged by the trephine. Small fragments of bone came away from time to time, but the case jtrogressed favorably, and on June ICth, 18C5, the patient was discharged from the service and pensioned. His disability is total. Case. — Captain A. V. Barber, Co. C, 31st Ohio Volunteers, aged 25 years, was wounded near Atlanta, Georgia, August 8th, 18G4, by a ball, which entered two inches above the left oibital plate, fracturing the frontal bone. He was admitted to the field hospital of the 3d division, Fourtcetilh Corps, on the same day, and on August 27th was transferred to the hospital at Chattanooga, Tennessee. On September ICth, the patient was sent to the OlBcers’ Hospital, at Lookout Mountain. Trephining was resorted to, and a poi tion of bone one inch in diametei’ was removed. The wound gradually healed ; a cartilaginous septum taking the place of the removed disk of bone. He resigned on December 15th, 18G4, and is not a pensioner. Case. — Private Lorenzo Beaver, Co. E, 7Gth New York Volunteers, aged 24 yeare, was wounded at Gettysburg, July 1st, 1SG3, by a piece of shell, which fractured the cranium. He was conveyed to Seminary Hospital, Gettysburg, thence was sent to JlcKim’s Mansion Hospital, at Baltimore, where ho received a furlough on October 17th. At its expiration he entered the post hospital, Albany, New York. The operation of trephining had been performed some time previously, but at what date cannot be exactly ascertained. He was transferred to Baltimore, leadmitted into McKim’s Mansion Hospital on December 9th, and was transferred to Jarvis Hospital, Baltimore, where he was disch.arged the service on February 5th, 18G4. On !May ICth, 18G4, Pension Examiner S. D. Will.ard reports that the man suffers from dizziness on bending or stoojjing. Being unable to bear exposure to the sun, and subject to e])ilcpsy, he was entirely unable to labor. His disability is rated total and permanent. Case. — Private Wesley Bonnett, Co. D, 111th New York Volunteers, was wounded at the battle of Gettysburg, Pennsylvania, July 3d, 18G3, by a eonoidal musket-ball, which fractured the right parietal bone. A few pieces of bone, and the ball, which was split in its long diameter, were removed on the field. He had received in the same engagement a penetrating wound of the lower lobe of right lung. He was taken to the regimental hospital, thence sent to Letterman Hospital, and on September 8th, 1863, admitted to Mower Hospital, Philadelphia. The wound of chest had entirely healed, and the patient’s health was good. He stated that he had been attacked, about four days after the reception of the injury, by epileptiform convulsions, which continued at intervals of two days until July IGth, when they ceased; but on September 5th they returned with increased violence. On Se])tember 9th, eight small fragments were removed. On September IGth, a convulsion threatened, but was warded off by counter irritation and half a grain of morphia. On the 20th convulsions suddenly occurred, and recurred twice afterward on the 2Gth and the 27th, followed each time by slight fever. On September COth, the patient was doing well with the exception of some headache occasionally, and the wound was healing kindly. He was discharged from the service on November 2d, 1833. From January, 18G4, to May, 1868, with the exception of one interval of fort}’ days, he had two or three convulsive seizures a week. On Jlay 25th, 18C8, the trephine was applied by Dr. Darwin C’olvin, and some depressed bone removed, A large piece of scmii-osseous material was removed by Hey’s saw, and also two sinirs of bone, which dipped down so that some jiressure must have been constant upon the brain. In July, 1868, the wound had closed with healthy granulations, and the patient was nearly well. A complete history of the operation is published in the Kcio Yorlc Medical Journal, vol. 7, page 422. The man is not a pensioner. Case. — Private Sterling Bunnel, Co. G, Gth Connecticut Volunteers, aged 22 years, was wounded at Bermuda Hundred, Virginia, May 20th, 18G4, by a eonoidal ball, which fractured the right frontal bone, near its union with the parietal. He was admitted on the following day into the hospital at Hampton, Virginia, and tlience transferred, on June 3d, to the Knight Hospital, New Haven, Connecticut, whei’e he arrived on the 7th. HaDinofrhage had occurred the day previous, and the patient was very feeble. The wound looked healthy, and the case progressed favorably until the morning of the 12th, when severe haemorrhage recurred from a branch of the anterior temporal artery. The bleeding vessel was ligated, and the haemorrhage ceased. On Juno IGth, the wound became unhealthy, red, and tumefied, and flax-seed and charcoal poultices were applied, and morphine in small doses and stimulants were ordered. Gangrene became fully developed on the following day. During the next day the slough was dissected and bromine applied. The gangrene was entirely arrested, and by the 30th healthy granulation had set in. During the afternoon of Jfdy 2d, severe convulsions, followed by loss of consciousness, supervened. The wound was carefully examined, but no depression could be discovered. An accamulation of pus being diagnosed. Acting Assistant Surgeon S. D. Wilcoxson applied the trephine. No pus was found, but a light depression of the inner table was discovered and elevated. Low diet and perfect quiet were enjoined. No unlavoi-able symptoms recurred. The patient was furloughed on August Gth, and returned at the expiration of his leave, when the wound was reexamined, and a portion of bone removed. From that time rapid improvement took place, and on Sejitember 3d, 18G4, he was discharged from the service ; his term of service having expired. The case is reported by the operator. Acting Assistant Surgeon S. D. Wilcoxson. On October 20th, 18G4, Pension Examiner Henry Pieiqiont reports that the wound had not perfectly healed. The right eye was affected, and pulsation was jdainly visible. Any excitement, or even a short walk, caused severe pain. His disability is rated total and temporary. Further information states that in 18G9 Bunnel's disability was considered total. A portion of the skull four and three-fonrths by one and three-fourths inches was missing. The jmlsations of the brain were plainly visible, and excitement caused severe pain. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 289 Case. — Pi-ivate William Burt, Co. G, 2il New York Heavy Artillery, aged 30 years, was wounded near Petersburg, Virginia, Juno 17tli, 1804, by a conoid.al ball, wbicli fractured and depressed the left parietal bone. He was admitted to the Second Corps field hospital at City Point, on June 19th, and conveyed to the Campbell Hospital, Washington, on the 28th. He was in a stupid condition, and the i-ight arm and leg had become paralyzed. On the following day. Surgeon A. F. Shehlon, U. S. V., removed about one and a half inches square of depressed bone with the trephine. The patient rallied after the operation, and continued to improve. By the 20th of July he had regained the use of the paralyzed parts. On the 28th he was transferred to the' Lovell Hospital, Portsmouth Grove, Rhode Island, where he remained until the 24th of August, when he was sent to the JIcDougall Hospital. Fort Schu 3 -ler, New York Harbor, lie was discharged the service on December 15th, 18G4. On August IJth, 1865, Pension Examiner E. Bradle.y reports that the patient’s hearing and ej’esight are very poor. There was partial hemiplegia of the right side, accompanied bj' anemia and weakness to such a degree as to incapacitate him for anj' manual labor. It appears that this man’s health continued to deteriorate, as his pension was subsequentlj' increased. Case.— Private George W. Burton, Co. E, 5th Wisconsin Volunteers, aged 21 j'ears, received, near Petersburg, Virginia, Api'il 2d, 1865, a compound fracture of the occipital bone, and also a fracture of the left tibia. He was admitted to hospital 1st division. Sixth Corps, where the skull was trephined, and a portion of the left tibia excised. He was, on April lOth, admitted to Broad and Cherrj' Streets Hospital, Philadelphia, and on !May 8th sent to Satterlee Hospital, where he was discharged from the service July 24th, 1865. He was pensioned, and in Julj', 1865, Pension Examiner E. A. Smith rated his disability total and per- manent. The pulsation of brain was still visible. The leg was unhealed and the tibia necrosed. Case. — Lieutenant William 0. Capers, Co. C, 14th Tennessee Regiment, received, at the battle of Perryville, Kentucky, October 8th, 1862, a severe gunshot fracture of skull, with depression. He was admitted to a Confederate held hospital near Perr^’ville, where the skull was trephined. Ho was discharged October 24th, 1862. Case. — Private George W. Coates, Co. F, 8th Minnesota Volunteers, aged 18 years, was wounded at Murfreesboro’, Tennessee, December 7th, 1864, by a conoidal ball, which fractured and depressed the-right parietal bone near the coronal suture. He entered the general hospital at the above place on the following day. The wound was hot and painful. Violent and frequent epileptic convulsions commenced on the third day after the injury. On the 11th he was gi’owing stuj)id, with tonic spasm of the muscles of tlie jaw and neck, and irregular and depressed pulse. He was placed under the inhuence of chloroform, and Surgeon Samuel D. Turney, U. S. V., trephined a portion of the inner table. Considerable haemorrhage from the veins of the diploii ensued. He reacted promptlj'. A silver plate was inserted, and water-dressings were applied, and cathartics administered, 'riio convulsions diminished in frequency and violence, and finally ceased entirely. On February 16th, 1865, the patient was trans- ferred to Hos])ital No. 2, Nashville, Tennessee, and furloughed on February 28th, 1865. On April 2d he was admitted to the hospital at Murfreesboro’, and was discharged from service July 4th, 1865. The case is reported by the operator. On August 2d, 1865, Pension Examiner S. Willey reported that the patient was weak and anaemic. The right limbs were smaller than the left, the pupils were dilated, and there was inability to distinguish objects with the left eye. His disability is rated total and temporary. [In a letter of December, 1873, Dr. Turney disclaims the superstition of silver plate. See Second Sure/kal Volume, p. 283, Case 815, and Note 5.] Case. — Private Andrew Cole, Co. D, 145th Pennsylvania Volunteers, was wounded at the battle of Fredericksburg, Vir- ginia, December 13th, 1862, by a conoidal ball, which fi-actured the frontal bone, right side, near the coronal suture. Another ball jiassed through the muscular substance of the thigh. He was admitted to Plarewood Hospital, Washington, December 17th, 1862. On December 23d, the skull was trephined, and loose fragments of bone were removed. No inflammation existed, and wound suppurated freely ; several pieces of bone were removed at dift'erent periods, but in March, 1863, the wound had neail^' healed He was discharged December 21st, 1833, and pensioned. In February, 1864, Pension, Examiner D. E. Belknap reports that the wound is still open and discharging, and that more bone will probably come away. The disability is rated total. Case. — Private Russell M. Cool, Co. E, 9th Illinois Volunteers, aged 19 years, was wounded at Fort Donelson, Tennessee, February 15th, 1862, by a conoidal musket ball, which fractured and depressed a portion of both tables of the left parietal near the junction with the occipital bone. He was conveyed to Mound City, Illinois, and entered the hospital at that place on the 20th, when Surgeon E. C. Franklin, U. S. V., performed the operation of trephining, being obliged to apply the trephine in three places before the depressed bone could be elevated.- Fourteen pieces were removed; the largest was the size of a five-cent piece. All the symptoms of compression were manifest; pulse 65; breathing stertorous. Twenty -four hours after operation the pulse was 85, the breathing natural, and the appetite good. Cold water dressings were applied. In about a week sloughing commenced and increased the size of the wound to five inches in length, by one incli in breadth. Two weeks after admission. Cool was furloughed. He returned to the hospital on June 21st, and was discharged the service on the following daj'. In the early part of 1866, he was examined by Pension Examiner Thomas S. Stanway, who states that “ a little to the left of the junction of the parietal and occipital bones a depression is found, which would hold about two drachms of fluid. The man’s health was good, but exposure to the sun’s raj^s would affect him.” On September 27th, 1867, Pension Examiner T. S. Stanway reported that partial amaurosis of the left eye had occurred, and that the disability increased upon exposure or fatigue. His disability is rated total. Case. — Private Owen Fitzpatrick, Co. B, 63d New York Volunteers, aged 48 years, was wounded at the battle of the Wilderness, Virginia, May 5th, 1864, by a musket b.all, which struck anterior to the superior angle of the occij)ital bone, fracturing both tables of the skull and depressing a portion of the Inme to the extent of one-fourth of an inch. He was conveyed to Alexandria, Virginia, and entered the 3d division hospital on May 12th. Little, if any, constitutional disturbance existed; the patient ate and slept well and was able to walk about. On the 16th, he was placed under the influence of chloroform and ether, equal parts, and Surgeon Edwin Bentlej’, U. S. V., trephined the skull, removed a few small fragments, and elevated the depressed bone. No hajmorrhage followed the operation. Cold wat(^r dressings were a])])lieil, tin? h(!ad slightly elevated, and (juiet and abstemious diet strictly enjoined. The case progressed without any untoward symj>toms. On June 2541], some small 290 WOUNDS AND INJURIES OF THE HEAD, pieces of skull and shreds of cloth were removed from the wound. On September 26th, the wound had entirely healed and the patient received a furlough of thirty days, at the expiration of which he returned. On December 20th, 1864, he was discharged fi’om the service on surgeon’s certificate of disability, by reason of dizziness and headache which supervened any exercise. A communication from the Commissioner of Pensions, dated January 3d, 1868, states that Fitzpatrick is a pensioner, and that his disability is rated as one-half and permanent. The case is reported by Surgeon E. Bentley, U. S. V. On Januaiy 28th, 1870, Pension Examiner J. W. Toward reports from the National Military Asylum at Augusta, Maine, (of which institution the patient was an inmate,) that there was a deep indentation at the seat of the wound. There was complete loss of sight of left eye and the vision of the right eye was much impaired. The patient suffered from headache, dizziness, temporary loss of sight of right eye, and was unable to remain in the sun or perform any labor requiring stooping or much exertion. Since he was wounded he was subject to fits of an epileptifonn character, which supervened upon unusual exertion. His disability is rated total and permanent. Case. — Corporal E. Eugene Flagg, Co. K, 94th Illinois Volunteers, was wounded at the battle of Prairie Grove, Arkansas, December 7th, 1862, by a conoidal musket ball, which fractured and depressed the cranium two inches posterior to the coronal, and one and one-fourth inches to the left of the sagittal suture. Assistant Surgeon Archibald E. Stewart, 94th Illinois Volun- teers, trephined the skull, and removed all fragments of bone, on the field. The patient was immediately admitted to the field hospital at Prairie Grove. In the beginning of January, 1863, his condition was favorable and daily improving, but the right leg was partially paralyzed. He was transferred to the general hospital at Springfield, Missouri, on February 15th, and discharged from service February 20th, 1863. The case is reported by Surgeon Ira Russell, U. S. V. On May 21st, 1867, Pension Examiner H. Conkling reports that the patient at times suffers from pain in the head and paralysis of the left leg. The left eye was also affected. His disability is rated two-thirds and permanent. Further information in 1869, regarding this man’s pension, mentions the paralysis of the leg and the affection of the eye. Case. — Private Joseph Freeland, Co. A, 30th U. S. Colored Troops, aged 18 years, w'as wounded before Petersburg, Virginia, July 30th, 1864, by a shell, which fractured the cranium. He was at once admitted into the hospital 4th division, Ninth Corps, where, on August 2d, Surgeon David Mackay, 28th U. S. Colored Troops, trephined the skull, and removed one and onc-fourth inches of right parietal bone, while the patient was under the influence of chloroform. He was, on August 3d, transferred to hospital for colored troops at City Point, where he remained until August 8th, when he was transferred to L’Ouverture Hospital, Alexandria. The left arm and leg were paralyzed. He was discharged the service on June 8th, 1865. On May 15th, 1866, Pension Examiner B. Gesuer reports that there was general paralysis of the side. He rates the patient’s disability total and permanent. Case. — Private Brazilla Grant, Co. A, 6th New Jersey Volunteers, was wounded at the battle of Williamsburg, Virginia, May 5th, 1862, by a musket ball, which fractured and carried away a portion of both tables of the parietal bone near the central part of the sagittal suture. The brain was involved. For several weeks he remained in the field hospital. On June 12th, 1862, he was admitted into the Wood Street Hospital, Philadelphia. The wound healed, and the patient was discharged from service on August 8th, 1862, in consequence of a pai-tial paralysis of the right side. The case is reported by Assistant Surgeon C. W. Honter, U. S. V. On January 25th, 1867, Pension Examiner W’’. S. Combs reports that the operation of trephining had been performed. The result was a complete paralysis of the left side, incapacitating the patient for any kind of manual labor. He rated his disability total and permanent. A communication from the Commissioner of Pensions, dated December 9th, 1869, stated that Grant receives a pension of |)15 per month, and that his disability is rated permanent. Case. — Private Thomas Hailey, Co. K, 7th Minnesota Volunteers, hged 24 years, was wounded on August 9th, 1864, during a skirmish on the Tallahatchie River, Mississippi, by a conoidal ball, which struck the left parietal bone half an inch from the sagittal suture, depressed both tables for a space of one inch in diameter, and lodged. He was conveyed to Memj)his, Tennessee, and entered the Jackson Hospital on the 12th. The lower extremities were paralyzed. 'I'he pulse was 85, feeble and compressible, and his spirits were verj’ much depressed, 'rhe soft parts around the injury were extensively lacerated, and the depressed bone was so wedged that it was impossible to move it with an elevator. A few hours after admission, he was ])laced under chloroform, and Acting Assistant Surgeon Samuel S. Jessup trephined the skull anteriorly and externally to the point of injury, and removed the depressed bone. The lips of the incision were then brought together again by sutures. The patient reacted promptly. Ice water dressings were applied to the wound, drastic purgatives administered, and the patient placed on low diet. The paralytic condition ceased within a week after the operation, and progress was rapid. On October 6th, he Was furloughed, the wound being nearly healed. He reported at the general hospital at Fort Snelling, Minnesota, on November 30th, 1864, and was discharged from the service on April 29th, 1885. He was examined in 1867, by Pension Examiner Otis Ayer. There was a depression about an inch and a half long, an inch wide, and five-eighths of an inch deep, midway between the frontal and occipital bones; had pain in head, perverted sensation in the limbs, and j)hysical exercise produced.a mental condition in which he Avas unable to recognize his most intimate friends. He is a pensioner. Case. — Private Franklin Harris, Co. E, 145th Pennsylvania Volunteers, was wounded at the battle of Fredericksbiu-g, Virginia, December 13th, 1832, by a conoidal ball, which fi-actured both tables of the left parietal bone, depressing the inner table; ho also received flesh wounds of left shoulder and right hand. Hu was taken to the field hosjuta! of Hancock’s division. Second Corps, where, on December 22d, the trephine Avas applied, and fragments were removed and the edges of bone elevated. The patient improved gradually; Avas transferred to Broad and I’rime Streets Hospital, Philadelphia, on January 6th, 1863, and thence sent to South Street Hosjjital, on January 11th. The brain pulsations Avere distinctly visible. Small pieces of bone came aAvay nearly eA'ery day, but the scalp Avas granulating freely, and disposed to close over the opening. On January 26th, there being a boggy feeling in the A’icinity of the Avound, and consider’able discharge from betAveen it and the bone, free incisions Avere made in the scalp by Acting Assistant Surgeon J. Walter Tiyon. By February 15th the discharge of pieces of bone had ceased; the patient had become drowsy and listless, but the discharge from beneath the seal)) continued. Iron, quinine, and TEEPniNING AFTER GUNSHOT FEACTUEES OF THE SKULL. 291 beef tea were ordered. The patient’s general condition was much improved, and the wound had nearly closed by the 23d of March, but he complained of much pain over the left eyebrow. He was discharged fi'om the service on May Cth, 18C3. He is not a pensioner. Case. — Private Philip L. Hart, Co. B, 7th Connecticut Volunteers, was wounded in the engagement at James Island, South Carolina, June 16th, 1832, by a shell, which fractured the cranium, and injured the right thumb, causing loss of first joint. He was probably treated in a field hospital until end of December, 1862, when he was conveyed per steamer Star of the South to New York City, entering St. Joseph’s Hospital, Central Park, January 1st, 1863. He' suffered from cephalalgia, occasional attacks of vertigo, and impairment of intellect. He was discharged February 2d, 1863, and pensioned. In May, 1864, Pension Examiner J. W. Ellswoith reports that the operation of trephining has apparently been performed; that the patient-has pain in the head when exposed to the sun. Partial loss of thumb inteiferes materially with his work. The disability is one-third and permanent. Case.— Private Alvan A. Hasty, Co. K, 38th Massachusetts Volunteers, was, on June 17th, 1863, admitted to Sj. Louis Hospital, New Orleans, Louisiana, with a gunshot wound of the cranium. The operation of trephining was performed. The patient recovered; was furloughed on September 6th, and discharged December 15th, 1863, and pensioned. Pension Examiner George Stevens Jones reports that he suffers from pain m the head, vertigo, and nausea, which increases by over exertion or exposure to heat, and rates the disability two-thirds and probably permanent. Case. — Corporal William H. Hurst, Co. I, 150th Pennsylvania Volunteers, aged 22 years, was wounded before Peters- burg, Virginia, July 15th, 1834, by a piece of shell, which fractured the left parietal bone, without known depression. He was, on' the same day, admitted to the hospital of the 1st division. Fifth Corps, and on August 6th conveyed to the Grant Hospital, Willet’s Point, New York Harbor, where he remained until September 21st, when he was sent to the Cuyler Hospital, German- town, Pennsylvania. On May 10th, 1865, he was transferred to the Mower Hospital, Philadelphia. Only simple dressings had been applied to the wound up to this time. It seems that at this latter hospital the operation of trephining was performed. The man recovered, and was discharged from service on June 7th, 1865. On June 9th, 1865, Pension Examiner H. L. Hodge reports that the injury to the skull had been followed by necrosis, cephalalgia, loss of memory, and absent-mindedness. Ho rates the patient’s disability one-half and probably permanent. A communication from the Commissioner of Pensions, dated March, 1868, states that Hurst is a pensioner, at four dollars per month, and that his disability is rated one-half and permanent. Case. — Sergeant Monroe Holloway, Co. I, 67th Ohio Volunteers, aged 25 years, was wounded in an engagement at Fort Wagner, near Charleston, South Carolina, August 18th, 1863, by a fragment of shell, which fractured the right parietal bone at the posterior inferior angle, causing a slight depression. He was rendered insensible by the shock, but soon recovered, and was carried to the hospital on Morris Island. In about forty-eight hours convulsions supervened, and continued for a week or more. Fragments from both tables were then removed, exposing the brain, and the convulsions ceased. On the 1st of September, he was sent to Hospital No. 1, Beaufort, South Carolina; the wound being dressed in the ordinary manner. On October 2d, he was transferred by steamer to the McDougall Hospital, New York Harbor. As late as December the wound had not closed, but convulsions had not recurred since the date of operation ^ no paralysis existed; and the patient was able to walk about ; indeed, he declared that he felt well. On February 12th, 1884, he was sent to the DeCamp Hospital, and on June 21st, 1864, discliarged from service at his own request. On August 29th, 1866, Pension Examiner W. Eamsey reports that the operation for trephining had been performed, and that the patient then complained of pain in the head, and dizziness. He was compelled to avoid mental as well as physical labor. His disability is rated one-half and permanent. Case. — Private Ambrose F. Jackson, Co. Gff 7th Rhode Island Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot injury of the cranium. He was admitted to the hospital of the 2d division. Ninth Corps; on December 20th, sent to Carver Hospital, Washington, and on January 6th, 1863, to Lovell Hospital, Portsmouth Grove, Rhode Island, where he was discharged on June 10th, 1883. On March 7th, 1867, Pension Examiner A. E. Ames reports that the patient had been trephined. He suffered from headache and dizziness, and his memory was so much impaired that he could not recollect the day or the year he was wounded. He recommends that the patient should have a full pension. Case. — Private Hezekiel Jackson, Co. K, 39th U. S. Colored Troops, aged 24 years, was wounded near Petersburg, Vir- ginia, July 30th, 1864, by a shell, which fractured the right parietal bone. He also received a wound of right leg. He was admitted to hospital 4th division. Ninth Corps, where the operation of trephining was performed, on August 2d, by Surgeon David Mackay, 29th U.'S. Colored Troops. One and a half inches of bone were removed. He was, on the same day, trans- ferred to hospital for colored troops at City Point, Virginia, where he remained until August 8th, when he was sent to L’Ouver- ture Hospital, Alexandria, Virginia. The left arm had become paralyzed. He was discharged from service April 7th, 1865, and pensioned. Pension Examiner Wm. H. Clendenin reports that he has occasional headache, but no paralysis or loss of memory. The wound of leg is entirely healed, leaving no disability. Case. — Private J. W. Jenkins, Co. F, 48th Pennsylvania Volunteers, was wounded at the battle of Antietam, Maryland, September 17th, 1862, by a piece of shell, which caused a punctured fracture of the anterior superior portion of the left parietal bone, and depressed the inner table. He was admitted into Capitol Hospital, Washington, on the 23d, and thence transfeired to the De Camp Hospital, David’s Island, New York Harbor, on the 28th. On October 3d, Acting Assistant Surgeon William K. Cleveland applied the trephine ^o the point of fracture, and removed two pieces of the depressed internal table an inch and a quarter in diameter. A few drops of pus escaped. With the exception of a slight headache, there had been no symptoms to denote the presence of pus. Patient made an excellent recovery, and was discharged from the service on December 4th, 1862. The case is reported by Surgeon S. W. Gross, U. S. V. On December 23d, 1869, Pension Examiner D. L. Beeser reports that the parts are well closed by a film tissue, and that the patient alleges to suffer neuralgic pains and vertigo at times. His general appearance was good, and he seemed robust and healthy. He rates his disability at one-third. His claim for a pension was pending at the above date. 292 WOUNDS AND INJURIES OF THE HEAD Case. — Private John R. Kell, Co. G, 22cl Illinois Volunteers, received, at the battle of Belmont, Missouri, November 7th, 18G1, a depressed fracture of both tables of the occipital bone, about one inch to the right of lateral sinus. He was conveyed by steamer to Mound City, Illinois, and entci'ed the hospital at that place on the 13th. Surgeon E. C. Franhlin, U. S. V., applied the. trephine, removed the depressed bone, and pared off the suppurating edges of the scalp. A spicula of the inner table was found driven into the substance of the bi’ain. The case progressed favorably, and on January 22d, 1863, Kell was fuiloughed. He subsequently returned to his regiment, and was discharged from the service by reason of epilepsia on July 16th, 1862. He is not a pensioner. Case. — Private Joseph Loughrey, Co. G, 22d Indiana Volunteers, was wounded at the battle of Perryville, Kentucky, October 8th, 1862, by a musket ball, which struck the parietal bone near the temporal ridge and above the ear, and comminuted both tables, depressing the external table one-fourth of an inch. On the 14th, he was admitted into Hospital No. 4, New Albany, Indiana. The wound was doing well, and there were no indications of injur.y to the brain. He continued to improve for two weeks, when he became restless at night and slightl.v delirious. On October 28th, symptoms of compression appeared, and an operation became necessary. Two sections of the injured bone were removed Avith the trephine. The inner table was found to be greatly comminuted, but there was no evidence of pus having formed in the brain. For several days he had Avild delirium, which finally gave Avay to active purgation. He recovered, Avith the exception of a slight nervous derangement, and Avas dis- charged December 4th, 1862. The case is reported by Acting Assistant Surgeon M. N. Elrod. On January 21st, 1863, Pension Examiner George W. Mears reports that the wound had healed, and that the man, although’ previously weak, then labored without inconvenience or pain in the head. He rated him as not disabled. A communication from the Commissioner of Pensions, dated January 3d, 1888, states that Loughrey is not entitled to a pension, having been rejected by the examining surgeon Jul.v 17th, 1863. Case. — Private Thomas A. Moore, Co. K, 33d Missouri Volunteers, aged 23 years, Avas Avounded at the battle of Helena, Arkansas, July 4th, 1863, by a conoidal ball, Avhich fractured and depressed both tables of the frontal bone above the right frontal eminence. He Avas conveyed to Memphis, Tennessee, and admitted into the Gn.voso Hosjiital on the 7th, Avith slight symptoms of compression. Acting Assistant Surgeon S. Leslie performcvl the operation of trepliining, leaving an opening an inch and three-fourths by one inch. The depressed portion of bone Avas much comminuted, and a portion of the ball Avas Avedged into the fracture. A large quantity of blood Avas found in the brain. The folloAving day the patient Avas doing Avell. Water dressings and low diet were ordered. On the 9th, and again on the 11th and 12th, haemorrhage occurred from the Avound, amounting to tAvelve or thirteen ounces ; otherwise the case progressed Avithout any untoAvard symptoms, and on September 1st Moore received a furlough for thirty days, at the expiration of Avhich he Avas admitted into the Jefferson Barracks Hospital, St. Louis, Missouri. He Avas discharged the service December 14th, 1863. Acting Assistant Surgeon S. Leslie reports the case. On December 18th, 1866, Pension Examiner J. Bates reports that the patient suffered from headache, frequent giddiness, and a conscious fiiilure of memory. He Avas unable to perform any manual labor. His disability is rated total and permanent. Case. — Private LeAvellyn Mowry, Co. B, 25th Massachusetts Volunteers, aged 18 years, was wounded at Cold Harbor, Virginia, June 3d, 1834, by a conoidal ball, Avhich entered over the left eye at the outer margin of the superciliaiy ridge, frac- tured the bone and lodged. He Avassent to Washington, and on June 8th Avas admitted to Finley Hospital. On November 1st, he Avas transferred to the hospital at Readville, Massachusetts, and on December 20th, 1864, Avas discharged the service. The vision of the left eye Avas impaired. On June 10th, 1868, Pension Examiner John G. Metcalf reports that he finds an ulcer, five inches from the old cicatrix, four inches above the right eye, of a triangular shajAe, Avith equal sides, one inch long. The frontal bone Avas rough, and at tAvo points a pi'obe could he passed throu|rh the outer table. In September, 1868, a portion of both tables of the frontal bone, at the bottom of the ulcer, had been removed by the trephine. The ulcer discharged piAjfusely, and the patient Avas very feeble. On October 2d, 1868, Dr. Metcalf states that the Avound had healed, leaving an indentation iibout three-fourths of an inch deep. The patient’s disability is rated total and permanent. Case. — Corporal Ii’a B. NeAvkirk, Co. E, 5th Wisconsin Volunteers, aged 23 years, was Avoimded May 5th, 1864, at the battle of the Wilderness, Virginia, by a conoidal ball, Avhich fractured and depressed the osfrontis above the superciliary ridge. He Avas admitted into Judiciary Square Hospital, Washington, on the 11th. Tavo days later he Avas placed under ether, Avhen Assistant Surgeon Alexander Ingram, U. S. A., made an incision one and a half inches in extent from the point of entrance, reflected the flaps, applied the trephine, and removed all the tlepressed bone, a portion of Avhich Avas pressing on the dura mater. The parts were bi’ought into apposition^ and tAvo sutures applied. The patient’s constitutional condition Avas very good. Ice Avater dressings Avere applied, and saline cathartics administered. No untoAvard symptoms occurred, and on J uly 16th the patient ’AVas returned to his regiment. He Avas discharged July 30th, 1864. He is not a pensioner. Case. — Private William G. Parker, Co. A, 76th Noav York Volunteers, aged 32 years, was Avounded at the battle of Cold Harbor, Virginia, June 2d, 1864, by a conoidal ball, Avhich fractured the cranium. He Avas, on the following day, admitted to the hospital of the 4th division. Fifth Corps, Avhere the operation of trephining Avas performed. On June 12th, he Avas sent to the Campbell Hospital, Washington, Avhere he Avas discharged from the service on July 10th, 1835. Ho is not a pensioner. The case is reported by Assistant Surgeon J. S. Billings, U. S. A. # Case. — Private Joseph R. Phillips, Co. H, 2d Michigan Cavalry, temporarily assigned to the 27th Michigan Sharpshoot- ers, aged 43 years, Avas Avounded at the battle of Spottsylvania Court-house, Virginia, May 12th, 1864, by a conoidal ball, Avhich fractured the superior portion of the right parietal bone. He Avas, on the same day, admitted to the hospital of the Ninth Corjis, and thence conveyed to Washington, Avhere he entered HareAvood Hospital on the 25th. 'Phe skull Avas tre])hined and simple dressings Avere ap)»lied. He recovered rapidly, Avas furloughed on June 28th, and discharged from the service on October 22d, 1834, by reason of exjnration of term of service. He is not a pensioner. TREPniNINO AFTER GUNSHOT FRACTURES OF THE SKULL. 293 Case. — Corporal Geoi-ge W. Pliillips, Co. 15, 30tli Ituliana Volunteers, aged 21 years, was wounded during llie siege of Nasliville, Tennessee, December ICtli, 18C4, by a shell, which fractured the cranium at the ])ostcrior fontanelle. I’ortions of the bone were removed on the field, while the patient was ii. a state of partial insensibility. lie was admitted to the hospital of the 3d division. Fourth Corps, and thence conveyed to Nashville, where he was admitted to Hospital No. 3 on the following day. On January 8th, 1865, he was transferred to the Jefferson Hospital, Jeffersonville, Indiana, and thence sent to Columbus, Ohio, entering Tripler Hospital on the 24th. The patient stated that the skull had been trephined, and a silver plate inserted one month after the reception of the injury, and that complete paralysis of the left side had existed for two months. When admitted to Tripler Hospital he could use his arms, but had to go on crutches, on account of want of control over lower limbs. His general health was good. Cold water dressings were applied. He was discharged from the service on May 2Cth, 18G5, the wound having healed, except a small sinus. There was a crucial cicatrix two inches long from before backward, and one inch wide, a de])rcssion one-fourth of an inch at its greatest depth, and partial paralysis of the left side. In July, 1868, Phillips was a pensioner, his disability being rated total and permanent. The case is repoi ted by Acting Assistant Surgeon J. M. Abraham. The patient applied for an increase of pension on November 25th, 1868, but his claim was not admitted. On January 8th, 1869, Pension Examiner S. C. Sapp reported that the patient’s mind was impaired, and that lie could not bear exposure to heat without falling over. He rates his disability permanent. Case. — Private John Shaffer, Co. D, 18th Missouri Volunteers, aged 38 years, was wounded at the battle of Shiloh, Tennessee, April 7th, 1862, by a conoidal ball, which fractured the left parietal bone, near the sagittal suture. He was taken prisoner, and probably remained in the hands of the enemj' until October 3d, 1863, when he was admitted to the Washington Hospital, Memphis, Tennessee. He recovered, and was returned to duty October 27th, 1863. On December 26th, he was again admitted to Hospital No. 4, Louisville, Kentucky ; March 19th, 1864, transferred to St. Louis, Missouri, and on September 4th sent to Simon Hospital, Mound City, Illinois. The records of the latter hospital state that the trephine had been api)lied, and a large portion of the parietal bone removed prior to admission. No particulars as to date and mode of operation can be obtained. The wound was discharging, and the patient w'as suffering from headache and epilepsy. On the 22d of the same month he was transferred to Jefferson Barracks, Missouri, and discharged from the service March 1st, 1865. He is not a pensioner. Case. — Private M. F. Sheffler, Co. E, 39tli Illinois Volunteers, was wounded at Fort Wayne, August 15th, 1863, by a conoidal ball, which struck the frontal bone near the coronal suture, one and a half inch from the apex of the frontal bone. The injury at the time was considered a slight scalp wound, which healed rapidly. The patient was placed on light duty, and no bad symptoms were perceptible from continuous daily labor. In January, 1864, he began to experience a feeling of numbness in his privates, nates, and right limb, which increased and finally extended to the left limb, and at the same time he began to suffer from difficulty in voiding urine. Under the impression that he had the gravel, he was subjected to a bathing process for a period of seven weeks, without any beneficial results. He consulted Drs. Fox and Johnson of Washington, who pronounced his disability to be a general disease of the spine. On his second visit he told Dr. Johnson that he had been wounded in the head, and the doctor informed him that an operation would be necessary to procure relief. In November, 1867, the case came under the observation of Dr. C. M. Clark, who decided on an operation, which he performed on December 9th, 1867. Ether was administered to the patient, and a crucial incision made through the scalp and the flap turned back; the periosteum was scraped off, when the bone immediately over the fracture seemed loose in texture, and blood began to ooze from the wound. The trephine was applied by Surgeon C. M. Clark, 39th Illinois Volunteers, so as to cover all the depression, and a button of bone.one inch in diameter and one-fourth of an inch in thickness was removed. The patient was allowed to recover from the anajsthetic before the section was complete; sensation and motion returned the instant it was lifted, and he walked unaided to his bed. On the following day a mild aperient was given; he rested well, but had a slight chill in the morning. On the 12th there was still slight numbness about the perineum; the wound had united except at point of incision, where there is slight suppuration. His strength gradually increased, and on December 24th, walked a distance of three miles. He went home on January 14th, 1868, entirely recovered. He is upt a pensioner. Case. — Private Nelson J. Ward, Co. K, 62d Ohio Volunteers, aged 19 years, was wounded at the battle of Appomattox Court-house, Virginia, April 9th, 1865, by a conoidal ball, which fractured and depressed the left j)arietal bone. He was immediately coTiveyed to the field hospital of the Twenty-fourth Corps, where the depressed portion of bone was removed with the trephine by Surgeon S. A. Richardson, 13th New Hampshire Volunteers. On April 10th, he was transferred, and on the 17th entered the hospital at Point of Rocks, Virginia. He was, on May 16th, sent to the West’s Buildings Hospital, Baltimore; on May 22d, to the Jarvis Hospital; on July 24th, to the Hicks Hospital, and finally discharged from the sei-vice on August 26th, 1865, and pensioned. In J une, 1866, Pension Examiner G. W. Livesay reports that the man has freciuent attacks of epilepsy, sometimes several within twenty-four hour.s, and that the disability is permanent. Hernia Cerebri . — Tins complication was observed not infrequently: Case. — Private W. A. Baden, Co. E, 1st Maryland Cavalry, was wounded in an engagement October 12th, 1863, by a conoidal ball, which struck the left parietal bone about midway between top of the ear and the vertex, glanced a little down- ward and backward, and made its exit in a track of one and a half inches in length. He was admitted to the Chimborazo Hospital, Richmond, Virginia, October 19th, 1863, at which time he could give no account of himself, seemed timid, shy, and easily agitated. On October 22d, the scalp was freely incised from the wound of entrance to that of exit; the cranium was found to be fractured, comminuted, and depressed. Portions of bone were removed with probe and force])s. Five days later, hernia cerebri, of the size of a common marble, appeared ; the divided edges of the meninges could be distinguished upon the base of the cerebral protuberance. On October 26th, tlie ])rotnuled brain began to disappear by sujipuration, and had disa])])ea.red entirely by October 31st, when the patient was somewhat mpre intelligent. On November 3d, an abscess appeariMl over llu! occipital bone a little to the left of the median line and about four inches from vertex, which was ojicned. On examination, a 294 WOUNDS AND INJURIES OF THE UEAD fracture of the occipital bone was discovered. Tlie outer table was elevated and a piece of lead was found closely impacted between the plates; all attempts to remove it without trephining proved inetfectual. The ball had been split when impinging upon the parietal bone and a portion of it had passed within the cranium, making its partial exit through the occiput. On January 31st, 18G4, the patient was doing well, all the wounds in the scalp had cicatrized; a depression in the parietal bone marked the site of fracture and a projection of outer table of the occipital bone existed, the lead still remaining between the tables of the bone. The patient recovered, but remained somewhat childlike and was easily confused in mind. He was discharged on October 4th, 18G4. Case. — Private Thomas Haley, Co. D, 91st New York Volunteers, aged 28 years, was wounded at Petersburg, Virginia, March 29th, 1865, by a piece of shell, which fractured the frontal bone just above the right eye, causing hernia cerebri. He was admitted to the hospital of the 1st division. Fifth Corps, on April 2d; sent to City Point, and thence conveyed to Washing- ton and admitted to the Armory Square Hospital on April 10th, 1865. Simple dressings were applied to the wound. On April 27th, a piece of the orbital bone which had become loose was removed, otherwise the case progressed well, and on July 18th, 1865, Haley was transferred to New York for muster out. He is not a pensioner. Case. — Private William H. Hogan, Co. K, 14th Virginia Infantry, was accidentally wounded on January 15tb, 1863, by the discharge of a musket. The missile entered on the postero-lateral portion of the right side of the head, passed forward and upward across the parietal protuberance and emerged, exposing the skull for a distance of three inches, and fracturing the parietal bone. lie was admitted to the Chimborazo Hospital, Richmond, Vii’ginia, on January 23d. His mental faculties were perfect, and there Was very little constitutional disturbance and no paralysis. A triangular portion of the bone had been removed, through which opening the brain was protruding. He stated that when wounded, there was complete paralysis of the left side. Cold-water dressings were applied to the wound, and a compress to the protruding portion of the brain, which caused it to slough. The bowels were kept open, and the patient kept on light diet. The bone became necrosed along the whole track of the bull, and was removed, exposing the brain for two inches, after which the wound healed rapidly, with a depressed cicatrix. The patient was returned to duty on July 21st, 1863, perfectly cured, with the exception of an occasional headache. Case. — Sergeant Borden Joline, Co. G, 1st New Jersey Cavalry, was wounded near Sulphur Springs, Virginia, bn October 12th, 1863, by a conoidal ball, which entered the cranium directly over the right eye, about two inches above the superciliary ridge. Ift entered the Judiciary Square Hospital, Washington, on the 14th, and was furloughed for forty days. On March 18th, 1864, he entered Ward Hospital, Newark, New Jersey, his general health being good. A small opening still remained at the wound of entrance, discharging a slight quantity of pus. There was no swelling, redness, or inflammation of the parts. On May 3d, Acting Assistant Surgeon James B. Cutler, made a crucial incision at the tvound of entrance, reflected back the flaps, and extracted the ball, which was partially impacted in the skull, and partly in contact with the substance of the brain. The missile was very irregular and misshapen. Cold water was kept applied to the wound, the head was kept elevated, and strict antiphlogistic treatment employed. Hernia cerebri formed, three or four days after the operation, with a profuse discharge from the wound. The hernia was pared off on a level with the scalp, but, on July 6th, it reappeared, when slight pressure was applied. By August 23d, there was no hernia or discharge. The wound was entirely closed, with no impairment whatever of the mental faculties, and the patient was doing remarkably well. On August 26th, 1864, he was transferred to Trenton, New Jersey, to be mustered out of service. This man’s name is not on the pension roll. Case. — Private David Jones, Co. A, 1st Virginia Regiment, was admitted to the 1st division hospital, Alexajidria, Virginia, on May 3d, 1863, with a gunshot wound of the head. The missile, a musket-ball, entered one-fourth of an inch above the middle of the right supra-orbital arch, fractured the outer table of the frontal bone, and taking a semicircular course, lodged above the right ear, whence it was extracted. The left upper eyelid was very much swollen, completely closing the eye; and there were symptoms of fever, with considerable pain. Cold-water dressings were applied, and the swelling gradually subsided. On May 20th, an incision was made, and a quantity of pus evacuated, which relieved the parts and improved the condition of the patient. On June 2d, a piece of bone came away, and on June 12th erysipelas attacked the oi bital region. The wound was laid freely open down to the frontal bone, which was found to be denuded of periosteum. On June 23d, the erysipelas extended all over the face, forehead, and right side of scalp; the tongue was furred, bowels loose, and appetite poor. Through the wound protruded a large tumor, the size of an orange, caused by thickening of the periosteum. A solution of sulphate of iron was applied to the infected parts. The symptoms being of a typhoid character, the patient was treated with fresh breeze day and night, beef tea, brandy, and flax-seed enema. On July 1st, the tongue had become moist and the stools more natural. On July 6th, the tumor was dissected, and isinglass plaster applied. The edges of the wound were then gradually approximated, and a steady improvement followed. He was sent to the provost marshal on July 20th, 1863. The case is reported by Surgeon W. A. Conover, U. S. V. Case. — Lieutenant Charles Kennedy, Co. I, 28th Pennsylvania Volunteers, aged 25 years, was wounded at the battle of Chancellorsville, Virginia, May 2d, 1863, by a fragment of shell, which produced a wound two inches long and one inch wide, removing the superior portion of the occipital bone one inch to the right of the median line, destroying the membranes so that the substance of the brain protruded about one and a half inches. On May 7th, he was admitted to Armory Square Hospital, Washington. The wound had a burnt and black appearance, and the pulsation of the brain was very distinct with every beat of the heart. The patient’s intellect was greatly impaired, and there was total loss of vision, so that he could not distinguish day from night. The pulse was at 60 and full, and there was partial loss of power in the lower extremities. After admission to hospital, the hair was closely shaven around the wound, and the dead tissue was removed by sponging with tepid water. Ilis bowels were constipated for seven days from the date of the injury, and he had scarcely any sleep. Cathartics, injections, and anodynes were administered. On May 11th, twelve leeches were applied to each temple, and three behind each ear. On the following day the symptoms were greatly ameliorated. On May 13th, spicqja; of bone were removed, and also on ti % I \ m -^r. 5 / *# I? it i ¥ . • , ' V ' t. • *A IkV* ✓ Med a Siirg Uiiit of' tJie Wur of Uio Kel)ellion. I’ert T. VolU. Oppose I. LI. Llitvrk'S KoniiPfty , ( Sec pag'r I 2 . The same two months later, ( S('e pa<;e ‘295. ) TREnilNING AFTER GUNSHOT FRACTURES OF THE SKULL. 295 tlie ir.tli, wlicn the fungus had receded somewhat, and a liealthy granulation was progressing. Ilis a]ipetit(! was good, no fever, vision pai'tially restored, and able to get out of bed. He continued to improve, and on June lOth the fungus had entirely retracted, and vision was restored. The intellect was perfect and the general health good. On June 20th, Lieutenant Kennedy went home on leave of absence. He was subsequently admitted to the Officers’ Hosj)ital at Philadelphia. On September 9th, 1833, the wound had entirely healed. On November 12th, he was ordered before an examining board at Annapolis, and was returned to duty January 12th, 18C4. On May 5th, 1864, he was admitted to the field hospital at Lookout Mountain, being again returned to duty about July, 1864. He was discharged the service July 20th, 1864, and afterward pensioned. Pension Examiner Wilson Jewell, under date of April 19th, 1865, reported that the patient suffers from cephalalgia, vertigo, and weak- lu'ss, when exposed to the sun or much excited. His disability was rated one-third and temporary. It was subsequently stated by Dr. C. C. McGlaughlin, late surgeon 95th Pennsylvaida Volunteers, that he attended Lieutenant Kennedy in his last illness, and that he died December 15th, 1865, from the effects of a wound in his head. The plate opposite illustrates the appearance of the wound in May and June, 1863. Case. — Private P. E. A. Williams, Co. I, Palmetto Sharpshooters, aged 23 years, was wounded in an engagement near Petei’sburg, Virginia, June 19th, 1864, by a conoidal ball, which impinged upon the superior portion of the frontal bone, left side. The wound was one inch and a half in length antero-posteriorly, and one inch in width. The inner edge was half an inch from the median line ; the outer table was grooved by the ball, leaving the borders nearly smooth ; the inner table was broken into numerous spiculae, some of them pressing directly upon the dura mater, and some of the smaller ones penetrating the brain. He was stunned by the injury, but soon recovered consciousness, and again became comatose. The loose spiculae of bone were removed, and simple water dressings applied. He was sent to the Jackson Hospital, Richmond. His condition remMned critical for weeks. For two weeks symptoms of coma continued. Spiculm were removed as soon as they became detached, and the wound was kept carefully cleaned. By August 14th, his general coudition had improved; most of the spiculat had come away, leaving a large orifice, with clean edges. The dura mater was exposed and perforated by small orifices. Two months after the reception of injury, when all the circumstances attending the case indicated recovery, the cerebral substance began to protrude through the opening, but was not followed by .any serious symptoms. Compress was applied, and in two weeks the hernia cerebri had receded, and healthy granulation had sprung up. He was discharged from hospital about the middle of September, 1864, and returned to South Carolina. The wound remained open, discharging more or less until December, 1865, when it finally cicatrized firmly. In March, 1866, the orifice was filled with bony or cartilaginous matter, slightly depressed in the centre; the cicatrix is fair, mostly destitute of hair; his mind is unimpaired, but occasionally he suffers from slight vertigo ou stooping suddenly, or after much mental exertion. The case is reported by Confederate Surgeon F. S. Parker. * Case. — Private Richaid H. Baldwin, Co. H, 4th New York Artillery, aged 26 years, was wounded near Petersburg, Virginia, October 2d, 1864, by a conoidal ball, which fractured the frontal and parietal bones, left side. He was sent to hosj)ital of the 1st division. Second Corps, and, on October 3d, was sent to the Second Corps Hospital. Hernia cerebri supervened, and death occurred October 28th, 1864. Case. — Private James M. Bartin, 7th Georgia Regiment, received, at the battle of Bull Run, Virginia, July 21st, 1861, a gunshot fracture of the cranium. He was conveyed to a Confederate hospital at Culpeper, Virginia. Hernia cerebri super- vened, and death occurred August 11th, 1861. Case. — ^P rivate Otto Bockel, Co. B, 6th New Hampshire Volunteers, aged 18 years, was wounded near Petersburg, Virginia, July 19th, 1864, by a conoidal ball, which fractured the left temporal and parietal bones. He was conveyed to the field hospital of the 2d division. Ninth Corps, w'here several spiculm of bone tvere removed; thence he Avas transferred to Philadelphia, entering the Mower Hospital on July 22d. A fungous groAVth, or hernia cerebri, of the size of a pigeon’s egg, protruded through Avhat appeared to be an aperture in the cranium made by a large trephine. The patient seemed to be in full possession of his mental faculties; Avas cheerful, had a good appetite, and his general health Avas unimpaired. No signs of com- f)ression Avere developed. Damp compresses of patent lint, saturated Avith lime-Avater, Avere bound as firmly as consistent upon the fungus groAvth. Absolute quiet, a recumbent position, and light diet Avere ordered. On August 3d, the hernia had increased to the size of a psllet’s egg, and Avas taking on a vascular condition. Tlie general condition Avas but slightly changed, the pupils Avere natural, consciousness seemed nearly perfect, and pulse 70 and full. Dr. Morton examined and made an incision in the hernia. One of the small branches of the cerebral artery became divided and bled freely for some time. No change Avas per- ceptible on tbe 7th, except that the patient became more feeble and lost his appetite ; but by the 12th his appetite had again improved, and he seemed quite as Avell as usual. The hernia steadily increased, and the patient’s health beginning to be com- promised, it was decided to remove the protruding massj Avhich was noAV the size of an ordinary orange. Accordingly, on August 20th, Acting Assistant Surgeon \V. P. Moon passed a double-threaded curved needle beloAV the cranial tables, inclosing each half of the neck of the tumor, and after gently tightening the ligatures, the excrescence Avas shaved off' to a level with the external table. The patient exhibited little sense of suffering during the operation, but experienced a sense of relief on that side of the head. No antesthetic Avas used. Moderate pressure Avas noAV applied by means of a compress saturated with lime-Avater. On the 22d, the patient, though rational, began to fail. Incoherency, Avith a tendency to coma, Avere manifest on the 25th, AVhile the gi’OAVth seemed disposed to reappear. On the following day the patient Avas rapidly sinking. Motion atid sensation of the right side Avere lost, and the respiration became labored. Death ensued on August 28th, 1864. A post-mortem revealed in the left hemisphere a large abscess, from tAvo and a half to three inches in diameter, Avith softening of the surrounding tissue. All the vessels of the brain Avere considerably congested. A large trephine had been employed to remove the cranial fracture at the seat of injury. The case is reported by tlie operator. Case. — P rivate James E. Bridge, Co. C, 156th New York V(dunteers, aged 20 years, Avas Avounded at Fisher’s Hill, Virginia, September 22d, 1864, by a conoidal musket ball, which fractured the occipital bone above and to the left of the 296 WOUNDS AND INJURIES OF THE HEAD protuberance. He was admitted to tbe liospital of tlie 1st division, Nineteenth Corps, and on October sent via Sandy Hook Maryland, to the National Hospital in Baltimore, where he was admitted on October 3d. Hernia cerebri existed at that time. By the removal of detached fragments of bone at the dressings of the wound, the brain substance became exposed. Death ensued on October 18th, 1864. Cask. — Corporal Edward Briner, Co. B, 9th New York Volunteers, aged 23 years, a very robust man, was wounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a conoidal musket ball, which, crossing the coronal suture, fractured the right temporal and carried away a portion of the parietal bone two and a half inches in length and half an inch in width, exposing the membranes of the brain. He was immediately admitted to the held hospital, and on December 18th was transferi’ed to the Armory Square Hospital, Washington. The pulsations of the middle meningeal artery were visible. The wound discharged healthy pus, and the case progressed satisfactorily until December 26th, when the patient became restless, and stupor ensued, terminating in coma . O., I860, p. 9, I liave referred to seven hundred and four cases of gunshot fractures and injuries of the cranial bones, the results of which were then determined. Among these there were five hundred and five deaths, or a mortality of 71.7 per cent. In the report of tlie surgerj- of the Ilritish Armj- in tlie Crimea, already cited. Staff Surgeon T. 1’. JlATrUEW enumerates (op. cit,, Vol. II, p. 28G) oiglit hundred and ninety-eight gunshot wounds of the head, of which two hundred and thirty are classified as contusion or fracture or penetration or perfora- tion of bones of the cranium. Of these, one hundred and seventy were mortal, or 73.9 per cent. M. ClIENU, in his Crimean report (op. cit., p. 134), classifies two thousand seven hundred and seventy-four wound.s of the head under the four divisions of: fractures, undetermined wounds, simple wounds. 308 WOUNDS AND TN.TURIUS OF THE HEAD JIecapitulation and General Observations. — Leaving, for the moment, the gunshot injuries of the cranium, we may now sum up the injuries of the head from all causes, in order to engage in those general observations that apply to them in common, and such special remarks as have been deferred. The whole number of cases of injuries of the head from all causes, reported to this Office during the war, by name, was twelve thousand nine hundred and- eighty, which were classified in Table VII. Table VII. Naivure and Results of Twelve Thousand Nine Hundred and Eighty Injuries of the Head from all Causes, as reported during the War. INJURIES. Cases. Deaths. Disciiauges. Duty. Resuet UXKXOWX. 282 6 08 208 49 13 12 24 28 1 10 17 18 2 4 12 c 5 1 331 21 309 1 Concussions from blows, falls, railway accidents, etc 72 14 43 13 2 Fractures of Skull from similar causes. .105 57 28 17 3 Guihsliot Wounds of the Sctilp 7, 739 162 1, 170 3,089 2, 712 328 173 100 138 10 06 62 20 19 1 19 7 12 Gunshot Fractures without known Depression 2,911 1,820 051 309 125 Depressed Gunshot Fractures of the Skull 3C4 129 190 42 3 486 402 65 19 73 56 17 ■ 9 9 2 1 1 Agojreg.ates 12, 980 2, 774 2, 539 4, 821 2, 840 From these twelve or thirteen thousand cases, some particulars have been given in the foregoing pages of the histories of twenty-five hundred and thirty-two patients. Analyses of the abstracts of the three hundred and eighty-three cases in the first five subdivisions have been given on pages 15, 23, 31, and 34. The results of five hundred and eight injuries from miscellaneous causes, recorded in the next three classes of Table VII, are summed up on pages 61 and 69. and contusions, with a fatality of seven hundred and sixty-four, or 27.5. Of gunshot fractures of the cranium, M. CllEXU gives seven hundred and tliirty-onc cases, with five Imndred and forty-one deaths, cr a mortality of 74 per cent. In the Austro-Franco- Italian war of 1859, M. CllEXU (op. cil., T. II, p. 424) tabulates seven hundred and seventy-nine wounds of the head from all causes, witli four hundred and fifty-six deaths, a mortality of 58.53. These are elassified as contused, complicated, .and undetermined wounds, contusions and unspecitied (sans indications) injuries. There wore two hundred and thirty .three contused wounds by musket balls, with two deaths, and twelve from sliell fragments, with three deaths. There were fifty-two contusions from musket balls, with three deaths, and eleven from cannon balls or shell fragments, all of which were fatal. There were forty-tlyce undetermined wounds from small projectiles, and ten from large mi.ssiles, with four deaths. There were two hundred and twelve complicated wounds from musket balls and twenty-two from cannon balls or shell fragments, with a mortality of one hundred and eleven, cr altogether five hundred and ninety-five cases of gunshot injuries of the head, with one hundred and tliirty-four dc.aths, cr 22.5 per cent. Of the total number of gunshot injuries, it would appear that two hundred and thirty -seven were attended by fractures or grave injuries of tiie skull, with a mortality of one hundred and fourteen cases, or 48 per cent. Inspector General JIOUA'I' reports, from the Xew Zealand War, thirty-six gunshot wounds of the head among the ofBcers and men of the liritish Army. Of twenty patients with scalp wounds, all recovered .and were discharged to duty ; five cases of injury of the cranial bones, with two recoveries and three discharges for disability, and eleven fatal fractures of the cranium, with wounds of the brain. RECAPITULATION AND GENERAL OBSERVATIONS. 309 In the -earlier part of the chapter, commencing on page 95, ivith Abstract 1095, and ending with Abstract 1422, on page 126, memoranda of three hundred and twenty-eiglit gunshot contusions of the bones of the skull are noted, the results being analyzed on that and the two succeeding pages, to which- the reader must be referred for the conclusions that have been derived from a study of the individual cases. On page 140 is a summary of the one hundred and thirty-eight cases of alleged gunshot fracture of the outer table alone. From page 150 to page 159, the gunshot fractures of the inner table alone are discussed. Then follow a large number of cases of gunshot fractures of the cranium, without known depression, and of depressed or penetrating or perforating fractures; of these, only selected abstracts are printed, the summaries of the subdivisions being brief, as this, the most important part of the subject, is yet to be considered in the closing observations. The cases in which operations were performed are included in the aggregates of Table VII. It will be best, therefore, to give a separate table of operations, and then to sum up tlie remaining cases of gunshot fracture before proceeding to a more general discussion of the head injuries referred to in the foregoing observations. Table VIII. Results of Nine Hundred Cases of Injuries of the Skull in which Operations were performed- OCEUATIONS. Extraction of missiles Ligations Removal of bone splinters or elevation of de- pressed bone Formal trepanning Operations for bernia cerebri Abstracting from the twenty-nine hundred and eleven cases of fracture without known depression the eighteen hundred and twenty-six fatal cases, there remains one thousand and eighty-five cases, of which two hundred and sixty-two were subjected to some form of operative interference, and eight hundred and twenty-three were treated without a resort to such measures. Of these eight hundred and twenty-three cases, two hundred and sixty- nine were returned to duty, fifty-seven went to modified duty in the Veteran Reserve Corps, two hundred and seven were discharged, one hundred and thirty-five either exchanged, paroled, retired, furloughed, or released, thirty deserted, and in one hundred and twenty-five instances the ultimate result could not be ascertained. Of the two hundred and sixty-nine cases of patients returned to duty, the names of two hundred and thirty- four do not appear on the pension rolls; their histories present few particulars of interest; but in thirty-five cases of pensioners are some among which a few of the reports of the Pension Examiners are of interest; Nitscuke, a.. Sergeant, Co. A, 26th Wisconsin Volunteers, aged 23 years. Resaca, Georgia, May 15th, 1864. Treated at Briflgeport and Milwaukee. Duty, March 15th, 1885; discharged .lune 24th, 1865. Examiner .lames Diefendorf, M. 1)., reports, July 6th, 1835, his disability at three-fourths and probably permanent, and that the ball split on the frontal bone, separated in three parts, and destroyed a square inch of cranial parietes. Cases. £ Deaths. o c- Ui o ^ IlEMAKKS. 175 89 83 3 48.3 The missiles extracted from beneath the scalp or soft parts are not reck- oned in this table. 33 21 12 36.3 454 275 176 3 39.0 220 95 124 1 56. () 29 7 22 75.8 310 WOUNDS AND INJUKIES OF THE HEAD Kyax, P., Private, Co. F, 27th Indiana Volunteers. Gettysburg, July 3d, 1863. Fracture of left pariejal by fragment o shell. Treated at Camp Letterman, McDougall, and De Camp Hospitals. Duty, February 20tb, 1864; discharged October 10th, 1864. Examiner J. T. Dodds reports, January 10th, 1865, that there is a sulcus, showing a loss of osseous tissue one inch and a half long and three-fourths of an inch wide, and that the applicant stated that he suffered from vertigo and pain on stooping. Brown, NatHjVNIEl, Private, Go. D, 154th New York Volunteers, aged 29 years. Chancellorsville, May 3d, 1863. Treated at hospital of Eleventh Corps, Carver, and De Camp. Duty, May 11th, 1864; discharged June 11th, 1865. Examiner Thomas J. King, M. D., reports portion of frontal, about one inch in diameter, carried away; fistulous opening remains; several pieces of bone exfoliated; discharge still continues from opening; the pensioner suffers from vertigo. Sawyer, J. II., Private, Co. K, 11th New York Battery. Gettysburg, July 3d, 1863. Treated at Seminary, McDougall and De Camp Hospitals. Duty, February 11th, 1834; discharged December 6th, 1864. Examiner Samuel C. Wait, M. D., reports that the bullet struck the middle of the left frontal bone; necrosis and discharge of piece of bone; paralysis of left side for four weeks, and headache; cannot bear heat of sun nor warming influence of exercise or labor without severe headache, dizziness, and confusion of thought ; was of opinion that the bullet Avas still in the head. Harris, George, Private, Co. D, 35th Indiana Volunteers, aged 20 years. Kenesaw Mountains, June 18th, 1864. Fracture of left parietal by conoidal musket ball. Treated in Corps, Nashville, Louisville, and Evansville Hospitals. Duty, November 16th, 1864; discharged September 30th, 1865. Examiner E. E. Hawn, M. D., reports April 27th, 1869, mental faculties greatly impaired; is almost an idiot. Thompson, Helim, Corporal, Co. E, 44th New York Volunteers, aged 24 years. Gettysburg, July 2d, 1863. Fracture of nasal and temporal bones, and wounds of right shoulder and leg. Treated at regimental hospital and at York, Pennsylvania, and returned to duty, April 4th, 1865; discharged June 3d, 1865. Examiner George W. Cook, M. D., reports, March 27th, 1888, deafness in right ear, inability to close right eye, closure of nasal duct and paralysis of right cheek. SiLLOWAY, Benjamin W., Private, Co. B, 7th New Hampshire Volunteers, aged 39 years. Chapin’s Farm, October 7th, 1864. Fracture of frontal by conoidal ball. Treated at Tenth Corps hospital and Fort Monroe. Duty, January 8th, 1865; discharged July 20th, 1865. Examiner William G. Perry, !M. D., reports, January 12th, 1867, that about a square inch of the bone was gone ; that he cannot stoop Avithout becoming dizzy ; had headache most of the time. The remaining twenty-eight pensioners are reported as suffering from vertigo, head- ache, and other causes, disabling them from mental or physical exertion. Of the fifty-seven sent to the Veteran Reserve Corps, from the group of eight hundred and twenty-three cases, six were subsequently pensioned. Esselstine, L. W., Sergeant, Co. L, 1st Ncav York Cavalry, aged 26 years. Nbav Market, Virginia, !May 15th, 1864. Fracture of left mastoid process by musket ball. Treated at Frederick, Baltimore, and Elmira. Transferred to Veteran Eeserve Corps, January 3d, 1865; discharged July 24th, 1865. Examiner J. K. Stanchfield, M. D., states, April 23d, 1868, that he is deprived of the sense of hearing and poAver to close the eye, and that the facial muscles of the left side of the face are paralyzed. The five other pensioners of this class suffer from cephalalgia, loss of memory, partial paraplegia, and vertigo. The histories of the fifty-one patients who were not pensioned present few particulars of interest.* Of the series of two hundred and seven patients of this group discharged for disability, thirty were pensioned. A few abstracts are selected ; Kruger, B., Private, Co. A, 8th Ncav York Volunteers. Bull Eun, August 29th, 1862. Fracture of zygomatic process of left temporal. Treated at Fairfax Seminary, Washington, and Philadelphia. Discharged December 18th, 1862. Examiner Charles Phelps, M. D., reports that the sense of heai’ing of left ear is entirely destroyed, and that there is constant and profuse otorrhoea. Kahler, Leavis, Private, Co. I, 13th Ncav Jersey Volunteers, aged 44 years. Chancellorsville, May 3d, 1863. Fracture of occipital bone by conoidal ball, Avhich lodged beneath the mastoid process in sterno-mastoid muscles. Treated at Washington and discharged November 7th, 1863. Examiner T. B. Smith, M. D., November 9th, 1863, reports that the missile has not been removed and that it is the cause of constant irritation and stiffness of neck. Examiner Philip Leidy, M. D., March Cth, 1867, states that there is vertigo, dimness of vision, and pain in head, and that the poAver of locomotion is someAvhat interfered with. Wainwright, James A., Private, Co. I, 15th Netv Jersey Volunteers, aged 34 years. Cedar Creek, October 19th, 1864. Fracture of frontal bone by conoidal ball. Treated in field, at Baltimore, and Philadelphia. Discharged June 16th, 1865. Examiner Alfred Edeline, M. D., reports tliat there is dimness of vision and discharge of offensive matter from nostrils. The pensioner claims that the missile has not been extracted. The second finger of right hand has been amputated for gunshot Avound, leaving the other fingers contracted. *Ouc of these invalided men had suffered from erysipelas of the scalp; another had survived a copious hsemorrhage from the temporal arterjq on the thirteenth day after the injury, necessitating the ligation of the vessel ; and three had endured protracted convalescence because of necrosis of the skull, with frequent exfoliations. GUNSHOT INJURIES OF THE CRANIUM. 311 Cuimss, Robert G., Private, Co. D, 34tli Massachiiscfts Volunteers, aged 18 years. New Market, May 15tli, 18G4. Fracture of frontal bone by conoidal musket ball. Treated at Cumberland and Worcester. Discliarged June 2d, 18GG. There is loss of bony structure and his disability is rated three-fourths and permanent. CoUNTEitMiNE, CHARLES F., Private, Co. C, 14Ctli New York Volunteers, agetl £0 years. Five Forks, April 1st, 1865. Fracture of the left parietal bone by conoidal ball. Treated in field and at Washington, and discharged July 31st, 1865. Examiner M. D. Benedict, July 31st, 1865, reported that the inner table was depressed, and that the pensioner suffered from partial paralysis. Duxnixg, Eugexe H., Private, Co. I, 140th New Y'ork Volunteers, aged 21 years. Wilderness, May 5th, 1864. Treated in field, Washington, and Baltimore, and discharged July 9th, 1SC5. Examiner B. L. llorey, M. D., July 13th, 1869, reports that he believes that the inner table is depressed, and that the pensioner suffers from vertigo and defective vision. Hill, Gilliam, Private, Co. G, 31st Illinois Volunteers, aged 26 years. Kenesaw Mountain, Georgia, June 27th, 1864. Fracture of frontal bone, and injury of right eye by conoidal musket ball. Treated in field. New Albany, and Quincy, and discharged May 11th, 1835. Examiner John W. Mitchell, April 25th, 1866, reports that there is a cavity in the skull correspond- ing to the size of the bullet, and that exertion causes headache, vertigo, and dimness of vision. ICKERMAX, Frederick, Private, Co. I, 34th Illinois. Jonesboro’, September 1st, 1864. Fracture of parietal by musket ball. Treated in field, Chattanooga, and Nashville, and discharged July 12th, 1865. Examiner D. Trask Etter, M. D., January 14th, 1869, reports that the membrane of the drum of the left ear is desti'oyed. Luce, Albert, Private, Co. B, 17th United States Infantry, Gettysburg, July 2d, 1863. Fracture of the cranium. Examiner Edward F. Upham, June 6th, 1866, reports that the jaws cannot be separated, and that there is evidence of chronic softening of the optic nerves. The remaining twenty-one pensioners suffered in some instances from exfoliation and in most from cerebral irritability. Of the one hundred and seventy-seven soldiers who were not pensioned, about one-third were discharged b'ecause of the expiration of their term of service and the rest for such physical disabilities as vertigo, headache, mental imbecility, epilepsy, deafness, or defective vision. The reports of these cases record no unusual or peculiar symptoms or circumstances. The reports of forty-nine instances of recovery after gunshot fracture of the cranium without known depression, — cases of Confederate prisoners treated in Union hospitals and transferred to the Provost Marshal General for exchange, — afford little material for com- ment. hlearly all of the patients were very young men.* The duration of treatment in hospitals averaged about two and a half or three months. One of the cases was complicated by a perforating wound of the thorax ; another by several flesh wounds, and a third by variola. The confinement of these prisoners secured for them the advantages of absolute rest, and, usually, of restricted diet. As far as can be gleaned from the reports, the general treatment in the majority of cases appears to have been expectant or mildly antiphlogistic. The local measures were the shaving of the scalp in the vicinity of the wound and the application of cold-water dressings, except in one instance, of an inflamed scalp wound, which was advantageously poulticed. The cases of ten Confederate prisoners reported as “ paroled,” and of five whose surgical histories are terminated by the entry “released,” were of the same general charac- ter of those of the series just adverted to, and call for no remark, except that in one instance (Private W. U. Denmark, 9th Georgia Regiment, aged 18 years) nearly resembling that of Bemis (page 162, ante) in the extent of the wall of the cranium destroyed, there was no cerebral disturbance from first to last. In the Confederate Surgical records, histories are found of seventy-one cases of recovery from gunshot fractures of the cranium without known depression. Fifty-seven of the patients were furloughed, nine were retired, and five were sent to modified duty. *The oldest was Private W. Randall, Co. K, lOtli South Carolina Re^menf, aged 38 years, wounded at Snake Creek Gap, October 15tli, 1804. The next in age was Lieutenant J. N, Moore, 48th Virginia Infantry, wounded Jtily f)th, 1804, at Monocaey, aged 30 years. Tiio rest were from 20 to 25 years of age. 312 WOUNJJS ANU JN,JUIUES OF THE llEAH With few exceptions all of these patients sufferecl from very grave disabilities, ^ix of them were utterly disabled by complete hemiplegia, and others labored under partial paralyses. Two of them were blind, one was totally deaf, and one was affected by asphasia. Others had epilepsy. The gravity of the disabilities under which these officers and men were released from duty indicates tlie stringency of the examinations for discharge from service in the Confederate armies.* The series of thirty cases of deserters from hos})itals comprises none of any especial interest. In one instance, deafness had resulted from the injury ; but this is the solitary example of any complication of note. Of the undetermined cases from the Union army, a number probably proved fatal in transit to hospital ; others, perhaps slightly wounded, most likely went home ; the Confed- erate cases cannot be traced further, because the records of the southern hospitals are only fragmentary. The group of three hundred and sixty-four cases, included in Tables VI and VII, as depressed gunshot fractures, comprises all those examples of depression that are not 'included among fractures of the inner table, linear fissures, penetrating and perforating fractures, and cases of smash or of alleged fracture l)y counter-stroke. Doubtless this group should receive large additions from that of fractures without known depression. In these divisions there are slight discrepancies in the figures representing the final disposition made of cases, discrepancies arising from the fact that the tables were computed at different dates, and that cases entered as undetermined in one appear accounted for in the other. The successive transfers of patients from hospitals near the seat of operations to those more remote made it often difficult, as has already been remarked, to ascertain the ultimate results, except in cases of death, which were separately entered on alphabetical registers, so that the aggregates of mortality may be relied upon as nearly accurate. Some remarks have been already offered on pages 193 and 196 regarding the group of four liundred and eighty-six penetrating gunshot fractures, and abstracts of ninety-three cases are there given, while many others are cited under the headings removal of fragments, page 215, and trephining , page 261. The perforating gunshot fractures and the examples of smash and of alleged contre- coup are subdivided and commented upon on pages 206, 211,- 212, and 304. “ Nxdlum capitis vulnus contemnendum ” was the warning of Hippocrates. “ Nam veluti magna et gravia capitis vidnera non sequitur mors, sic et levia scepexmmero mortis causcB sint ” amplified Galen. “ No injury of the head is too slight to he despised, or too grave to he despaired of," paraphrased Liston, a text fully exemplified in the preceding pages. * For example, Surgeons F. N. Patterson, E. 1^1. AVaters, and J. B. Thomas, P. A. C. S., constituting the retiring medical examining beard, at Ilicliniond, in 1865, Iiave under consideration the case of Private James F. Blackwell, Co. E, ICth Virginia regiment, whom Captain Gover certifies to have been severely wounded in both thighs, at the battle of Sharpsburg, September 17th, 18G*i. This man was enlisted June 19th, 1861, to ser\'e twelve months. His application and Captain Covers certificate are approved by Major C. H. Clarke, commanding regiment, Brigadier-General M. D. Corse, I^Iajor-General G. E. Picket, and Lieutenant-General J. Longstreet, and the Beard finds: That the patient is “permanently disabled from any service in consequence of gunshot wound of the superior and posterior portion cf the right thigh;. ball passing behind the femur, and, coming out, reentered on the inner side of middle of left thigh, severing femoral artery, and fracturing femur, and finally making its exit two inches above the superior border of the patella. Left limb is considerably atrophied. He is therefore retired.” This paper is, approved by Assistant Adjutant General W. H. Taylor, by order of General R. E. Lee; but the Board is respectfully reminded of Par. \TI, G. O. 71, A. and I. G. O., 1864, and instructed that “if unfit for duty in the field, but capable of performing duty in some department of the scr\ffcc, the Board will specify for what position ho is best qualified, and, if he has here- tofore been detailed upon any light diity^ tlic Board will state how and when employed, and if his ser\dces are still desirable in such position.” The medical examining board near Petersburg, consisting of Simgeons H. H. Hubbard, G. W. Langdun, L. P. AVarren, B. F. Ward, and C. B. McGuire, I\ A. C. S., had before them in lilarch, 1865, among others. Private James Aycock, of Captain D. T. Hardin's company (C), of the 15tli North Carolina regiment, whose application being according to rule, and endorsed by the company, regimental, brigade, divisi(m, and corps commanders, is favorably considered on the ground that "a gunshot wound of the left parietal bone, fracturing it, and succeeded by paralysis of the right arm, received at South Anna bridge, July 4th, 1863, while in the scr\'ice of the Confederate States and in the line of duty” disabled him “from all duty.” This finding is approved by Assistant Adjutant General Venable, by order of General Lee; but the Board is reminded by an endorsement similar to that already quoted of the desira- bleness of assigning the applicant to “any light duty” in preference to retirement. LIGATIONS OF THE CAROTID. 313 The complications that may be present in injuries of the head arc htemorrhage, concussion, compression, cerebral irritation, foreign bodies, extravasations, meningitis, encephalitis, and purulent infection. I need not speak of concussion its signs are well known,, and no light has been thrown on its obscure pathology by the observations liere collected. External and intra-cranial hgemorrhages have been considered on pages 16, 80, 101, 255, and 289, and abstracts of fifty-three cases of extravasation of blood within the skull have been printed. All but three of these cases were fatal. In ten, trephining, and in nine, removal of fragments, were practiced, with success in only three instances. Hence it may be concluded that in intra-cranial bleeding due to gunshot injury, the fortunate results obtained by Keate and Tatum can be but rarely anticipated, though the teachings of Brodie and of Hewett regarding the management of extravasations due to other causes are not invalidated.^ Ligations. — In a few cases of gunshot wounds of the head, haemorrhage was con- trolled by tying the arterial trunks, with a larger measure of success than attended these operations in wounds of the face (p. 392), neck (p. 419), and spine (456). Ligations of the Common Carotid .- — -To arrest bleeding in cases of gunshot fractures of the skull, this vessel was tied seven times. The ligation by Surgeon E. Bentley, U. S. V., to arrest bleeding from the middle meningeal, is noted on page 255. The particu- lars of six other cases are reported as follows : Private J. S. Hayden, Co. D, 2d Iowa Volunteers, was wounded at the capture of Fort Donelson, February 14tli, 1862, by a musket ball wbich strucdv the loft ear, carried away the antilragus, perforated the temporal bone, and made its exit at the niasseter muscle on tbe right side, dividing the duct of Steno. He was sent to Third Street Hospital, at Cincinnati, where, on JIarch 2d, in an effort to remove fragments of tbe petrous bone, there was copious bsemorrliage, which was treated, but not arrested, by the free employment of persulphate of jron. Haemorrhage recurred on the 8th, and, on March 22d, chloroform was given, and Surgeon John Jloore, U. S. A., tied the carotid. Ligature came away on the twelfth day. The patient rapidly regained his strength, and was discharged convalescent July 23d, 1862. He was last heard from in 1868. He had facial paralj'sis. Professor J. A. Murphy reports the case. Private John Brooks, Co. I, 57th Pennsylvania Volunteers, aged 17 years, was Wounded at the battle of the Wilderness, May 6, 1864, by a conoidal musket ball, which entered ovei' the left eai-, jiassed forwards, making an irregular opening through the temporal bone large enough to admit the introduction of two fingers into the cavity of the skull, and escaped three inches anterior to the wound of entrance. The membranes of the brain, however, were not injured. He was treated in a field hospital and, on Jlay 15th, was sent to the Columbian Hospital at IV^ashington. He was ])ale, emaciated, and complained of acute cephalalgia ; otherwise, his bodily functions were nonnal. On the 17th, the headache had increased, and the pupils had become contracted. E.xpectant treatment was used, notwithstanding which, delirium gradually came on, and, on May 20th, the patient was comatose and unable to swallow-. Tbe pulsations of the heart were rapid and feeble ; the pulse at the wrist, imperceptible. He remained in tins condition sixty hours, when it was found that if fluids were placed in his mouth in small quantities, he would swallow them. From this time he slowly improved. On Juno 2d, the patient was able to sit up, but his bow’els were constipated, he voided his urine unconsciously, and his mental faculties were much impaired. He was unable to articulate, bad no recollection of the past or jiroper pei'ception of present things, and stared vacantly around the tent. His appetite was ravenous. The pupil of the right eye did not respond to light ; otherwise, there was no paralysis. At this date, a hmmorrhage occurred from the posterior wound to the amount of about two ounces, followed by great improvement in all the symptoms. Hmmorrhage recun-ed every two or three days, and was not altogether checked until the 18th of June, as it seemed to aid much in restoring ‘On this subject consult: COLQCnocx, G., De, cerehri concussione, Edinburgi, 3800; Haetman, A. II., Dc commotione ccrehri, Grj’phia:, 184G; Eageaxge, De la comm, du cerveau, These de Paris, 1808, No. 239; JIOUNIEU, Dc la commotion cerebral, These dc Paris, 1834, No. 119; llEl’IQUET, De la commotion du cerreau, These de Paris, 1818, No. 3f); IIuuxs, V., Die chirurgischen Krankheitcn und Verletzungcn des Gchirns and seiner Umhiill- ungen, TUbingen, 18.19, Hand I; GAMA, Traite des plaies de tete ct de V cncephalite, Paris, 1855, 2“' edition; Lauciee, S., Diet, de Med. ou Hep. Gen. dcs Sci. Med., 1‘aris, 1834, 'P. VIII, p. 453; Dleuyteex, Le^ns Orales, Paris, 18:19, T. VI, p. 170; JlAVEE, C., Dc commotione cerebri, ISerol., 181(i; Mai.eii, I>.; Dc commotione cerebri. Argent, 1777 ; P.txo, Memoire sur la commotion (Memoires dc la Sociele de chirurgie de I’aris. 1852). “ .See Jlr. PuESCOrr IIewett's remarks in Holme's System of Surgery, 2d ed., 1870, Vol. II, ]). 2.58; Sir P.EX.IAMIN' G. liEODlE (Med. Chir. Trans., Vol. XIV, p. 385) says: “blood is seldom ])Ourcd out in any considerable quantity between the dura mater and the bone, except in consequence of a laceration of the middle meningeal artery, or one of its principal branches; and it is very rare for tliis accident to occur, except as a consequence <.f fracture. If, therefore, we find the patient lying in a state of stupor, and, on examining tlie head, we discover a fracture, witli or without depression, extending in the direction of the middle meningeal artery, altliough the existence of an extravasation on the surface i f the dura mater is i:ot thereby reduced to absolute certainty, it is rendered highiy probable ; und tlie surgeon, under these cireumst:inccs, would neglect his duty if he omitted to tipply the trcivhine; and where no fracture is discoverable, yet, if there is otlier evidence of the injury h:»ving fallen on that I'art of the cranium in which the middle meningeal artery is situateil, the use of the trephine may be resorteil to on spccuhition, rather than that the i)aticnt should be left to die witiiout an ntteinjit being made f.jr his iireseivation.” Jt) 314 WOUNDS AND INJURIES OF THE HEAD his mental faculties. On the latter date, an atteinjit was made to ligate the tempoi'al artery ; and this failing, the common carotid was ligated at its upper portion, on Juno 20th, by Surgeon T. R. Crosby, U. S. V. The bleeding still continuing, the posterior wound was enlarged, and some small fragments of exfoliated bone were removed; the wound was then plugged with lint, which entirely arrested the hmmorrhage. It was estimated that fifty ounces of blood had been lost durlngthclasthannorrhage. Liberal diet was prescribed, and the patient gained rapidly in flesh. The ligature came away on the tenth day after the operation, and the wound united, except at the point of ligation, where a fistulous opening remained, which disch, urged daily a small tnnount of pus. On August 15th, blood was found to ooze from the place of ligation; and, the patient having lost about twenty ounces, the artery was cut down upon by Surgeon Crosby and ligated below the onio-hyoid muscle. The vessel was found dilated to more than double its normal size, and firmly attached to it, on the inner side, was a well-formed clot. Low diet was ordered; tincture of aconite was given to keep the heart’s action as much reduced as was consistent with the safety of the patient. On September 15th, the wound had fully healed, and, on November 15th, the patient was furloughed, apparently entirely restored in his bodily functions. He was discharged from service on J une 8th, 1865. The case is reported by Surgeon T. E. Crosby, U. S. V., and is figured as No. 284, .Surgical Photographs, A. M. M., Vol. VI, p. 34. Corporal A. J. Peckham, Co. I, 115th New York Volunteers, aged 30 years, received a shot fracture of the occipital, at Cold Harbor, Juno 3d, 1864, the ball entering at the right of the protuberance, and emerging at the right meatus auditorius. He was conveyed to Alexandria, and, on June Gth, on his admission to 3d division Hospital, in an anmmic state, the wound was swollen from extravasation under the scalp. On the 8th, Surgeon E. Bentley, U. S. V., gave chloroform and ligated the common carotid opposite (he thyroid cartilage. The bleeding continued after the operation, and the wound was filled with lint saturated with a solution of persulphate of iron. The patient lingered until .June 13th, 1864, and died from syncope. Fig. 1*. — Coagulum in distal porticn cf the left carotid si.v days after liga- tion. Spec. 317S1, .Sect. 1, A. M. M. Private Taylor McIntosh, Co. H, 40th Indiana Volunteers, aged 18 years, was wounded at Mission Ridge, November 25th, 1863, by a conoidal ball, which ente.red at the centre of the frontal bone, an inch and a half above the supra-orbital ridge, passed through the right orbit, and emerged near the angle of the lower maxilla. He was admitted on the next day to the field hospital of the 2d division. Fourth Corps. He was stupid and had partial convulsions at first, but subsequently regained his senses, although he was still dull and restless. The right eyelid and the right side of the face were swollen and ecchy- mosed. Cold applications were made to the wound. December 10th, evacuation of abscess in eyelid. By December 15th, he was able to make his wants Iniown and complained of pain in the eye and head. On the 16th, haemorrhage to the amount of sixteen ounces occurred from the wound of exit ; and, on the 17th, the right common carotid artery was ligated above the omo hyoid on account of the recurrent haemorrhage. He sank, and died December 19th, 1863, from exhaustion. Surgeon A. McMahon, 64th Ohio Volunteers, reports the case. Private Hiram B , Co. A, 142 Pennsylvania, aged 18 years, received a gunshot fracture of the zygoma and mastoid process of the temporal bone, left side, on the Weldon Railroad, August 21st, 1864. He was at once conveyed to the hospital of the first division. Fifth Corps, and, on the 24th, was transferred to Lincoln Hospital, Washington. The wound extended from within a half inch of the outer canthus of the left eye to just posterior to the left mastoid process. Cold-water dressings were applied. On the 26th, arterial hsemorrhage occurred, which was checked by filling the wound with lint soaked in a solution of persul- phate of iron. It, however, recurred on the next day, and Assistant Surgeon J. C. McKee, U. S. A., administered ether and ligated the left common carotid artery above the omo-hyoid, an inch and a half below the bifurcation. Anodynes and stimulants were administered, but the patient sank under the repeated and copious haemorrhages, and death ensued September 2d, 1864. At the autopsy, the meatus auditorius was found to be cut across. It was impos- sible to detect from what artery or arteries the haemorrhage proceeded. Both lungs were anaemic. The adjoining wood-cut (Fig. 1*) represents a portion of the aorta, the commence- ment of the left subclavian, the common carotid, and its bifurcation. A firm fibrinous coagu- lum extends from the seat of ligature to the bifurcation. The coagulum on the proximal side of the ligature is much shorter, occupying less than half an inch. The drawing is of the natural size of the vessels, shrunken in alcohol. The notes of the case, and specimen, were contributed by Acting Assistant Surgeon H. M. Dean. Private William C. Andrews, Co. A, 30th Iowa Volunteers, aged 19 years, was wounded by a fragment of shell, in the left temporal region, at Vicksburg, Deoember 28th, 1882. He was treated in a field hospital until January 17th, 1863, when ho was admitted to Lawson Hospital, St. Louis. On January 18th, haemorrhage amounting to twelve ounces occurred from the middle meninge.al artery, which, all other means failing, was arrested by Assistant Surgeon C. T. Alexander, U. S. A., ligating the left common carotid artery. The haemorrhage did not recur. Andrews was discharged from the service May 28th, 1863. In March, 18J3, he was a pensioner, his disability being rated as total and temporary. Pension Examiner A. C. Roberts, M. D., reports that he had a dizziness and faintness on exertion or stoojiing, and partial anaesthesia of the left side of the face, being compelled to keep his room in the cold winters of Madison, Iowa, from liability of freezing the left ear and face. Andrews remained intolerable health on June 1th, 1872, nearly ten years from the date of the operation. LIGATIONS OF AETEKIES, — SCALPING. 315 Of the seven operations above referred to, three of the four ligations of the left common trunk were successful, and the three ligations on the right side were fatal — or 57.1 per cent. Among face wounds, fifty-five cases,^ among wounds of the neck and spine, twenty-three cases, of ligations of the common carotid will be found, or a total of eighty-five operations, with sixty-three deaths, or a mortality of 74.1 per cent. Ligation of the External Carotid. — One case is reported among the head injuries : Private Francis L. Whitney, Co. B, 36th Massachusetts Volunteers, aged 24 years, was wounded at the battle of Cold Harbor, June 3d, 1864, by a conoidal ball, which fractured the external angle of the right orbit and the zygomatic arch, passed inward and downward, and lodged behind the right inasseter muscle. He was admitted to the hosjiital of the 2d division. Ninth Corps, and on June Sth was sent to the Emory Hospital at Washington. He had lost considerable blood, was anaemic, comatose, and suffered extreme pain, moaning constantly. Haemorrhage was arrested by compress to the external carotid, but recurred on the 14th. The patient was placed under the influence of ether and chloroform, when persulphate of iron was applied to the bleeding vessels, and the orifice plugged up with a styptic. The ball could not be found. Haemorrhage recurred on June 16th, 1864. The external carotid artery was now tied a little above the omo-hyoid muscle, and the ball was extracted from behind the masseter. The man died on the table from nervous exhaustion and anaemia. No anaesthetic had been employed at the second operation. Acting Assistant Surgeon W'’. A. Ensign, the operator, reported the case. Ligations of the Superficial Temporal.— EL ib vessel, or its principal branches, was tied twenty-two times for gunshot wounds of the scalp, alone or attended by contusions of bone or cranial fractures. Twenty cases have been enumerated." Two are here noted. Of the twenty-two, two were fatal from hgemorrhage, three from other causes : Private Eobert Faucett, Co. B, Sth Michigan Volunteers, aged 45 years, received a gunshot flesh wound of the scalp, on the right side, at Spottsylvania, May 6th, 1864. On May 10th., there was hsemorrhage fi-om the wound of about three ounces, and, other means failing to control it. Surgeon I. I. Hayes, U. S. V., applied a single ligature to the proximal end of the wounded vessel. The bleeding did not recur, and the man was transferred, convalescent, to W^hitehall, whence he was transferred to the Veteran Reserve Corps, January 23, 1865. Private Josiah Forbes, Co. L, 1st Vermont Cavalry, aged 19 years, received a gunshot scalp wound at Burke’s Station, June 24th, 1864. The wound became, inflamed and irritable and arterial bleeding took place, to arrest which, the right superficial tempor.al ai’tery was tied, at the Baxter Hospital, Burlington, Vermont, in July. The patient recovered and remrned to duty, September 29, 1864. Assistant Surgeon S. L. Thayer, U. S. V., the operator, reported the case. In connection with wounds of the scalp, an allusion to the custom of North American Indians, of scalping their victims, must not be omitted. This is practiced by making two elliptical, or four straight, incisions in the region of the vertex, and tearing off the ovoid or rectan- gular portion of integument thus enclosed. This is tanned, with the hair attached, and worn as a decoration. Crushing in the skull with a tomahawk is practiced, unless the van- quished is supposed to be already dead. Mr. T , a conduc- tor on the Pacific Railroad, while hunting near Cheyenne, in 1869, was attacked by Sioux, scalped, and left for dead.^ The wound (Fig. 2*) cicatrized in about three months, without exfo- liation. The opportunit}^ of skin-grafting was not improved. Foreign Bodies. — Many remarkable instances of the removal Fig. 2*. — Granulating surface a month after evulsion of a portion of the scalp. (From a photograph.) of balls'’ and other foreign bodies from under the scalp, or within the cranium, have been recorded. * Dr. Love’s ligation of the carotid for bleeding in a wound of the face, fatal from distal haemorrhage (case of Private Copeland., p. 347), is omitted in the summaries on pages 392 and 423, being included in the Statement, p. 394. 2 Namely, on page 81, successful cases of Private Fuller. Lieutenant Smitli, and Corponil Taylor; on page 82, cases of Lieutenant Gilmore, Privates Hartley, Mullen, Keesc, Corporals Talmadge, Kullman, and Private I). Jones; also, cases of Privates L. Jones, page 83; Newcombe, page 101 ; Sergeant R. D , page ICO; I'rivatcs Wlicclcr, page 22.5; Miller, page 241; Allen, page 244; Taylor, page 250; Runnel], page 288; Corporal E. Jones, page 298; Private Rrooks, page 313. 3 See Case 5 in rroceediings of the Second Anniversary of the Nchrasha State Med. Soc., June, 1870, Omaha, Nebraska, 1870, p. 22. ^ Since tlie case of Underu'oed, p. 281, was put in type, Or. R. Howard has published (Am. Jour. Med. Sci., October, 1871, N. S. ,\ ol. LXII, p. 385) an extended account of it. He states that he has “ hunted up a long list of wonderful recoveries after various injuries of the head,” but “has failed to find another case than the above in which a missile out of reacJi and out cf sight has been discovered and removed from the brain by trephining — a permanent rc<-o> ery afterward resulting.” He explains the recovery as due to “neither skill nor attention, but the will of Providence alone." Fig. 3*. — Portion of bul- let extracted from tlie anterior lobe cf tlic Icit cerebral hemisphere.— (.After H«)ward.] 316 WOUNDS AND INJUKIES OF THE HEAD, Of one Imnclred and eighty-six cases of halls penetrating the cranial cavity, one hundred and one were fatal ; in eighty-five cases of removal, there were forty-three recoveries ; of one hundred and one cases in which the foreign body was not removed, fifty-nine were fatal. Contre-Coup . — Consult the cases on pp. 43, 213, 304, and the authorities in the note.^ Trcphmmg . — Besides the two hundred and twenty cases of trephining already printed and enumerated in Table VIII, page 309, the nine following observations have been found on miscellaneous papers received since the preceding sections were placed in type : Private George W. Hamilton, Co. C, 4Cth Indiana Volunteers, received, at Jackson, Mississippi, July 12tli, 1863, a gunshot fracture of the cranium. He was taken to the field hospital, where Surgeon J. L. Dickon, 47th Indiana, performed the ojjeration of trephining. He was afterward treated in the Jefl’erson Barracks Hospital, and discharged on November 30th, 1863. He did not apply for a pension until February 7th, 1872. Pension Examiner J. M. .lustice reports, August 7th, 1872, that Hamilton’s disability is one-lmlf and permanent. He also states that the upper portion of the right parietal bone, to the extent of two inches in length and one and a half inches in width, is gone, leaving the dura mater exposed. The following^ is the only example, that has come to my knowledge, of hyperostosis following gunshot contusions of the cranial bones, as described by Mr. Hewett : Thomas S was struck, at Petersburg, in 1864, by a shell fragment on the right parietal, near the middle of the sagittal suture. There was no marked depression, and the constitutiomd symptoms were slight and soon abated. Two years afterward he had an epileptic convulsion, which recurred in three months, and tlienwith increasing frequency, until the paroxysms were diurnal. In 1871, Dr. J. T. Gilmore, formerly chief medical officer of the 1st Division of General Longstreet’s Corps, deteimined to trephine. The ]>erforation measured nearly .one inch in thickness. Meningitis followed, and was controlled by purgatives, mercurials, and veratrmn viride. The patient regained p)erfect health, and at the end of 1871 epilepsy had not I'eturned. John Berry', a stout and healthy civilian, at St. Louis, Missouri, on April 27th, 1864, fell fiom a horse, while in a state of drunkenness, striking his head against a curbstone. Soon after the accident, he was received into the Gratiot Street Hospital. On examination, the wound of the scalp 'was found to be about two and a half inches in length over the right parietal hone, and the bare bone was detected with some depression. Five days after the injury a trej)hinewas applied, and several pieces of bone were i-emoved. Three days after tlie operation, erysipelas supei vened ; for this, tincture of iron, quinine, and whiskey were administered, and the local application of tincture of iodine was used. The patient convalesced rapidly. On iMay 30th, he was able to walk about town and take full diet. About one month later he was discharged from the hospital. Iveportedby Surgeon B. B. Breed, U. S. V. A soldier of the 4th U. S. Heavy Artillery (colored) w'as struck on the head ^vith a spade, causing a compound fracture of the left parietal bone, with compression of the brain. He was at once carried to the regimental hospital at Columbus, Ken- tucky. Three hours after the reception of the injury, trephining was performed and the depressed bone was elevated. He was very drowsy for several days after the injury ; pupils irregularly contracted and dilated ; the pulse at one time falling as low as twenty-seven ; there was vomiting, obstinate constipation, and bloody' discharge from ears and nose. At date of the report February 28th, 1864, he was improving. Surgeon James Thompson, 4th U. S. Heavy Artillery', reported the case. An unknown soldier (German), while engaged in a drunken brawl at Washington, in June or July, 1861, received a blow on the head from the butt of a musket. He was admitted to the Washington Infirmary'. Assistant Surgeon J. W. S. Gouley, U. S. A., enlarged the wound, which was linear, and made an incision across it, bringing the fractured left parietal into view. There was apparently' but slight depression of the outer table. The inner table proved to be fractured in a stellate form and driven in about one-eighth of an inch. The crown of a large trephine having been applied, a disk of bone, including all the fragments, was removed. The patient had comatose symptoms. As soon as the operation was performed ho regained conscious- ness, but again lapsed into a state of stupor. On the following morning, he answered questions coherently. Eecovery took place without further untoward symptoms. Reported by the operator. I’rivate John H. Miller, Co. I, 134th New York Volunteers, received a blow upon the head at the battle of Gettysburg, .luly 1st, 1803, from a sword in the hands of his captain. He was taken to the Seminary Hospital, simple dressings applied, and on the 10th sent to Newark, New Jersey, and furloughed August 20th, 1863. While on furlough he came under the treatment of Dr. John D. Wheeler, of West Fulton, New York, who reports some depression of the edges f)f the fractured bone, which caused compression of the brain and hemiplegia of the right side. The patient had convulsions regularly once a week, and these symptoms becoming.more aggravated, on November 24th Drs. IVheeler and S. B. and H. Wells performed trephining. He was discharged I'rom the service Jlay 30th, 1864. He applied for a pension. The Examining Surgeon, Dr. J. Neill, reports that there was a deep indentation an inch in diameter along the middle of the left parietal bone, and rated his disability as three-fourths and permanent. WitAN, Bcclicrchcs sur les fractures de la base du erdne, (Archives generalcs de medecinc, 1844, Tom. VI, 4'“' serie.); Boketus, Theoph., Scpulchretum lih. IV, Sect, li, obserratio A' Geneva;, 1100 ; Celsus, A. C., Pc re medica libri octo, Lugduni, 159i2 ; CHOPAIIT, Memoire sur les lesions de la tetc par contre-coup, Paris, 1771; Gedia, Memoire sur Ic contre-coup, Paris, 1778; Goi'PlL, Dissertation sur les contre-coups dans les Blessures de la Tele, Paris, 1815; SlhuiiE, Traite des lesions de la iete p>ar contre-coup, jMeaux, 1773; .SaboI'RAVX, Memoire sur les contre-coups dans dcs lesions de la tctc, 1770; W'AGXER, P., De contra fissura, .Icna, 1708, in Haller's Disp. Chir., 'P. I, p. 15; VERlTh, De la guerison dcs fractures da rocker, These de J'aris, 1807, Xo. -59. 2 GILMOUE. Report of the Surgery of Mobile County for 1871, j>. 31 : IlEWETl', in Holmes's System of Surgery, 1870, Vol. II, je 248, Rath. Cat. It. C. S , Vol. II. p. 108, MSS. Surg. Cal. A. JI. M.. Spec. 513,5, licet. 2. TREPHINING OF THE CRANIUM. 3] 7" Private William H. Edwards, Co. U, 3d Iowa Cavalry, aged 23 j-ears, of good physical condition, was admitted into the hospital at Keokuk, Iowa, January 31st, lbt)4, with a fracture of the left parietal bone near its eminence, caused by a blow from a navy revolver, at Memjihis, January t;3d, 11:04. He was comatose and delirious; the soft parts were greatly lacerated and contused; there was a slight discharge of pus and blood; there was a circular depression of the fractui'ed bone less than one-half an inch in diameter. The opeiation of trephining being deemed advisable, Acting Assistant Surgeon 1). S. SIcGuigan made a crucial incision three inches by four and removed three large pieces of depressed bone, measuring from one-half to an inch in diameter, from the inner table, and half an ounce of coagulum situated on the dura-mater. The patient reacted well, with a complete return of all his mental faculties. Occasional epileptic fits followed the operation, and there was copious discharge of laudable pus; on February 20th, hernia cerebri, as large as a hen's egg, appeared ; lime-water and chloride of soda were applied without success, and saturated solution of sulphate of iron was substituted ; the hernia gradually declined, and he was discharged December 19tb, 1804. He applied for a pension, but his claim was rejected. The case is reported bj' the operator. Private John ilcTye, Co. G, Gth Tennessee ’\’olunteers, was struck on the head with a j)iece of steel, knocked insensible, and robbed, on February 7th, 1863.' He w as admitted into Hospital No. 1, Murfreesboro’, on the same day. The propriety of trephining was considered, but the operation was not performed. He apiparently recovered, and the wound gave him no trouble, and on March 23d he was transferred to Hospital No. 23, Nashville, where he was treated for diarrhoea ; on Ajnil 7th, while applying for a pass, he was suddenh' attacked with convulsions, and an examination revealed a depression over the fronto-jiari- etal suture sufiiciently large to insert the little finger; after consultation, a T-shaped incision w'as made, the trephine aj)plied, ;md three pieces of bone removed. On the 8th, he rested well, pulse 124, tongue slightly colored, and appetite poor; on the Oth, he was very much depressed in spirit ; on the 10th, he commenced sinking ; the parts around the wound became much swollen, and he died on April 11th, 1833. Private George Philips, Co. G, 1st Iowa Cavalry, received, at Austin, Texas, December 24th, 1864, a fracture of the left parietal bone, extending from the temporal to the right parietal bone ; another fracture parallel to and of equal length, one inch posterior, along the occipital suture of left side; the middle piece of bone was fractured at right angles to the other two at its centre and depressed about three-fourths of an inch. Trephining was performed by Acting Assistant Surgeon John Morris. The compression was relieved. The.j)atient died on the day of injury. The case is reported by the operator. Of one hundred and ninety-six cases of trephining for the results of gunshot injury, of which one hundred and ten, or 56 per cent., resulted fatally, the dates of operation were accurately ascertained in one hundred and sixty-two. Of these forty-six were primary, ninety-nine intermediary, and seventeen secondary operations. The comparative mortality rates were : primary, thirty-two fatal, or 69.6 per cent.; intermediary, hfty-six fatal, or 56.6 per cent. ; secondary, four fatal, or 23.5 per cent. If the thirty-four operations, of which eighteen were unsuccessful, were included in the intermediary and secondary groups, where they probably belong, the differences in favor of the latter operations would be diminished, but not removed. ‘ As to the degree of fatality according to the part of the cranium perforated, the results of one hundred and fifty-two operations for the efi’ects of shot ’fractures limited to one cranial bone, give the following results ; trejihining of parietal in eighty-five cases, * AknKMANN, D., Benicrkungen iiber die Durchhohrung des processus masto'idcus in gewissen Fallen der Tauhheit^ Gottingen, 179;^; Breyer, F., De trepanatione cranii in morbis capitis, Tubiug^e, lb3] ; BILLROTH, Til., Historische Studien ubcr die Beurthcilung und Behandlung der ScliussivuridoL vom 15, Jahrhundcrl his auf die neutsie Zeit, Berlin, 1859, p. 29; Baket, F. G., Essai sar la necessite dc V operation du trepan dans les plaies dc tele par armes d feu, Fans, 1815; BERLIN, A., Dc cranii trepanatione fiuadam, Berolini, 1828; Celinski, De trepanatione cranii, Diss., Bcruliui, J833; COXSTAIT, 11., Xonnulla de terehratione cranii lusionibus capitis adltihenda, Vratislaviaj, 1865; Dale, T. F., Depressed Fracture of the Cranium successfully treated, North Med. and Surg. Jour., Vol. X, p. 164; DORSEY, J. S., Fracture of the Skull and \Vound of the Brain, J^liila. Med. Jifuseum, Vul. II, p. 282, 18U6; FlOUUEXS, Considerations sur V operation du trepan, Faris, 1830; FISCIIEU, II., Klinisches und e.xpcrimentcllcs zur Lehre von der I'rejjanation, Berlin, 1865; GUILD, J., Case of Epilepsy cured by Trephining, Am. Jour. Med. Sci., Vol. IV, p. 96, 1829; IBeCKERT, C. A., De trepanatione, adjectis observationibus hue spcctantibus, Diss., Wirceburgi, 1826; IlAYAVOOD, G., Epilex}sy successfully treated by Trephining, Am. Jour. Med. Sci., Vol. XXII, p. 517, 1838; JIOLSTOK, J. G. F., Trephining for Epilepsy, Am. Jour. Med. Sci., Vol. XVII, p. 541, 1849; JUDKIXS, W., Chronic Injuries if the Brain rclicced by an Operation with the Trephine, Transyl. Med. Jour., Vol. II, p. 135, 1829; KauzmanX, M. F., Dc noco irepanationis instrumento, Diss., Erlangen, 1802; Kerxer, Til., De perforatione capitis, Vratisluviae, 18.56; Lefori’, DeVutilite et des indications de la trepanation du crane dans les lesions traumatiques de la tete {Gaz. llehd., 1867, Nos. 19, 20, 24); Ludwig, G. F., De novo trejjario pruccipue pro orbitw vulneribus atque de indole worborum verrialium, Tubingae, 1811; Le Buux'a, Biblioteka umiijctnosci lebarskich, Chirurgia Operacyjna, ^Varzsa\va, 1868; Laurey, M. l\., £tude sur la Trepanation du erdne dans les Lesions traumatiques de la tete, Faris, 1869; LOUVRIER, J., Abhandlungcn iiber die Durchhohrung des Schddels, Wien, 1800; Lauffs, J., Devariis Irepanationis methodis, Berloni, 1826; LEISNIG, A. F., Uber Trepanation, WUrzburg, 1844; i\lAL.vvAL, Frecis d'obs. sur le trepan in Mem. de V Ac. roy. de Chir., 1743 ; MOTT', V., Memoir on the Subsequent Treatment of Injuries of the Head, Trans. FhysicS- Med. Soc. of New York, Vol. 1, p. 223, 1817 ; Nesemanx, U., De terehratione cranii in htsionibus capitis adhibenda, Vratislavia?, 1858; NORRIS, G. W., lieporlof Casts of Injuries of the Head, Am. Jour. Med. Sci., Vol. IX, p. 304, 1831; Fare, A., Fractured Skull successfully trephined, Chapman's Phila. Med. Jour., Vol. VHI, 1824; Kichter, G. A., tjber Kopf vcrletzungen und die 'Treqmnaiion, Tubingen, 1863; BosER, W.. Zur Trcpanaiionslr.hre, in pamphlets, v. 224; BOGElts, D. L., Epilepsy from Depressed Bone, cured by Trephining, N. Y. Med. and I*hys. Jour., V<1. V, p. 18-6; liOLAXD, De trepanatione cranii, Berolini, 1844 ; '1 EXTOR, C., Vber die Nichtnothwendigkeit der Trepanation bci ScJiddcleindrache.n, V» iir/burg, 1835 ; \T:i.I’I:au, Plaies de tete, Dc l operation du trepan, Faris, 1854; VroLIK, Bcnierkuvgen uber dU Weisewie die OeJJiiung in dem Schddcl, nach der Trc 2 )anation, ^der andcrern Knochenverlust ausgefullt wird, Amsterdam, 1837; WarelnsiiEIN, Tldse de Paris, 1861, No. 58, Du trepan tn Anglelerre ; WIRMAXSKI. J., De cranii trepanatione, Berolini, 1831; WEEDS, J. F., Case of Cerebral Abscess. Nashville Jour, of Med. and Sci., April, 1872. 318 WOUNDS AND INJURIES OF THE HEAD forty fatal, or 47.1 per cent. ; forty-six of frontal, twenty-seven fatal, or 58.7 per cent. ; twelve occipital, six fatal, or fifty per cent. ; nine temporal, three fatal, or 33.3 per cent.^ Hernia cerebri.- — Sixty-one cases were reported, with eleven recoveries.* The varieties in form of fractures produced by falls, blows with various blunt weapons, small and large projectiles, are usually, but not invariably, sufficiently distinctive to bo recognized. The sword incisions, which cannot strictly be called fractures, though I have thus classified them (See Plate II and Figs. 1, 2, 3, 5), bayonet punctures (Fig. 8), fissures from falls on the vault (Figs. 12 and 14), are characteristic ; the fractures caused by blows often map out the form of the weapon (Figs. 15, 21, 24), as in the calvaria represented by Fig. The clean perforations made by small projectiles striking the skull perpendicularly at close range (see Circular 3, S. G. 0., 1871, Figs. 4 and 5), contrast with the irregular fractures pro- duced by the oblique impact of the same projectiles with lower velocities, and with the effects of shell fragments (Figs. 146 and 148). The adjoining cut (Fig. d'-") represents a calvaria contributed by Surgeon J. T. Flodgen, U. S. V., — case of Private James M- no. 4*. — Calvaria, showing the shell fracture near the vertex. Spec. 1013, Sect. I, A. IM. Fiq. 5 *. — Skull of a Pampa Indian fractured by the bolas, a ball attached to a cord, a Pata- gonian weapon. Spec. 972, Sect. I. A. ]\I. M. 24th Texas Cavalry, wounded by a shell fragment at Arkansas Post, January 11th, 1863, with injury of dura-mater ; died February 8th, 1863. Figure &'■' represents a pistol liall perforation at close range (see Catalogue of the Surgical Section of the Museum, page 25). It is a popular notion that leaden balls sometimes flatten against the skull without fracturing it. This is prob- ably erroneous. There is greatvariety in the mallea- bility of the lead used for projectiles ; but the mo- mentum necessary to produce flattening in the softest shot flattened on •L ° . the frontal bone. will generally suffice to overcome the resistance of 4473 . the hardest bone. The projectile represented in the cut (Fig. 7*) weighed only thirty grains, but fractured and depressed the frontal hone. Fig. 6*. — Internal view of segment of left parietal perforated by a pistol ball, the inner table beveled, but not fissured. Spec. 3220, Sect. I, A. M. U. • In the surgical report in Circular No. G, S. G. O., 1865, page 16, 1 stated that “Surgeon 1). W. Bliss, U. S. V., alone has reported eleven successes after the use of the elevator or trepliine.” It is true that Dr. Bliss has reported eleven cases, but I find on examining them that his success, though gratifying, was not uniform. Doubtless his success was overestimated, as, subsequently, in regard to the efficacy of cundurango in cancer, from reporting cases before the cures were confirmed. He had eleven cases bf trephining, with six recoveries, viz: 1. R , p. 59; 2. Morton, p. 125, fatal; 3. P , p. 266, fatal; 4. E , p. 268, fatal; 5. Clark, p. 269, fatal; 6. L , p. 272, fatal; 7. D — , p. 277; 8. E , p. 278; 9. G , p. 278; 10. S , p. 281; 11. Wolfe, p. 283; besides four cases of removal of fragments, namely: i. Wagner, p. 238; 2. 1C , p. 248, fatal; 3. IVIcConnville, p. 255, fatal; 4. Kennedy, j). 294, or fifteen cases, with eight recoveries. 2 AURUNI5TIIV, Surgical Hor/iTi*, Vol. II, 1830, p. 51; Allex, J. A., Fungus cerebri successfully treated by Excision, New England Med. Jour. Vol. VIII, p. 323, 1819; Buck, G., Researches on IJcrnia Cerebri following Injuries of the Head, N. V. Jour. Med. and Surg., Vol. IV, p. 348, 1840; COliviNUS, J. r. C., De hernia cerebri, Argentorati, 1749; DETMOLU, W., Abscess in the Substance of the Brain; Hernia Cerebri, the Lateral Ve.niricles opened by an Operation, Am. Jour. Med. Sci., Vol. XIX, p. 86, 1850; IlENNEX, op. cit., 3d ed., p. 316, case XLVII; IIEUSTIS, J. W., Case of Hernia cerebri cured. Am. Jour. Med. Sci., Vol. Ill, p. 350, 1829; Hill, .T., Cases in Surgery, Edinburgh, J872, p. 64; LOUIS, Sur le tumeur fongeusc de la Dure Mere, Mem. dc VAcad. royal de Chirurgie, Nouv. 6d., Paris, 1819, T. V, p. 9; SOLOMOXS, De cerebri tumoribus, Diss., Edinburgh, 1810; STANLEY, Cases of hernia cerebri, in Med. Chir. Transactions, Vol. Ill; Held, De hernia cerebri, Diss., Giessae, 1777. REMOTE RESULTS OF INJURIES. 319 The closure of the orifice made by the trephine is generally completed by the formation of a tough fibroid substance, with scanty, if any, deposition of callus. Hence the old surgeons used to protect these apertures by a metallic or leathern disk. The destruction of the pericranium and injury to the dura mater is assigned by physiologists as the cause of the absence of callus formation. The practical corollary is that it would be well to reflect, and preserve the pericranium over the space interested by the crown of the trephine. Klenke^ re|Torts cases in which these membranes were preserved and the bone was regenerated. The Museum can add one instance to the rare observations of the appearances of the perforations in the skull in those who have long survived trephining : A son of J. II. W , of Wasliington, a precocious lad of about twelve years, received, in 1842, a compound depressed fracture of tlie right side of the frontal bone, cau.scd by a blow from a stone. The integuments were drawn together by adhesive strips, and ab.solute rest, low diyt, and conlinenient in a dark room were enjoined by his medical attendant, Dr. Thornton. He recovered apparently without any untoward symptoms ; hut a few weeks afterward, Dr. Borrows was called to see him ou account of an epileptiform convulsion. This was ascribed to gastric derangement, and was treated as an ordinary fit. A few months after convulsions recurred, and continued with periodicity weekly. Fully three months now elapsed before any other sign of cerebral disorder was manifested. At last there was dulness of mind, vertigo, and greater frequency in the recurrence of the spasms. About three years after the accident, Dr. Nathan R. Smith trephined at the depressed part. The youth was comparatively well for six months afterward, when e])ilepsy recurred, and he gradually became idiotic. He lived till 1863. Physicially he was well devel- oped. These reminiscences of the case were furnished orally by Dr. Joseph Borrows. The specimen was contributed by Professor Johnson Elliot, of the Georgetown Medical College. Thetrephine aperture is 0.625 inches in diameter, and is closed by a tough diaphanous membrane, having a tendinous lustre, and appearing under the microscope as formed of layers of superim- posed horny epithelium. There is a falciform projection from the posterior surface of themem- 9»._i,iteriorview of s.anie specimen, brane, which musthavepressed upon the cerebral shoving the fibroid septum, with its falci- mass. No notes of the autopsy were preserved. ferin prcjcction. Fig. 8*. — Fxterior view of trepliine orifice eigliteen jears after operation. Sj>cc. 5024, Sect. I, A. JI. St. Surgeon Andrews," 1st Illinois Light Artillery, differs from Guthrie, and Irom the opinions commonly accepted, in regarding wounds of the anterior lobes as less, instead of more, fatal than those of other parts of the brain. * ■NVagner {Uber den Ilcilungsprozess vach Eesection und Extirpation dev Knochen, Berlin, 1853, 8. 23) refers to the paucity cf notices of dissections of persons who have sur\nvcd trephining for a long period. Consult DUBREUII. {Presse Medicate^ 1837); Guexsbuug {Deutsche Klimlc, Fig. 10*. — Kxterior view of a segment of the rigid side of the fnintal bone, deeply’ indented. Spec. 2019, Sect. J, A. M. 31. 1850, No. 8); Klexke {Physiologic dcr Enizuiu Leipzig, 1842, S. 197) ; HOICIT.VXSKI {Lchrbuch dcr Pathologischen Anatomic, AVien, 185^ 15. I, S. 179) ; Jameson, Case in which the Osseous Dish, removed by trephine, was regenerated, Mary- land Medical liccordcr, Vol. I, p. 152, 1829 ; IIUNAULD, Sur les os du erdnede I'hommcin Mem. de VAcad. dcs Sciences, 1730; VERlxf:, De la guerison des fractures du rocher, Thhe de Paris, 18G7, No. 59; Ollier, Traite experimental et Clinique de la regeneration des os, Paris, 18G7 ; AAgaroux, Opuscule sur la regeneration dcs os, Paris, 1788. Opportunities of examining the repair of depressed fractures of tlic skull, after the lapse of many years, arc not very common. Ilcncc the interest attaching to the specimen represented by the wood-cuts (FIGS. 10* and 11*J. The case is reported on page 1G5 ante, and the specimen is described at page 10 of the Catalogue of the ‘Surgical Section of the Aluscum. nnd Degeneration in Organischen Geweben, Fig. 11*. — Interior view cf the foregoing speci- men. Spec. 2GI9, Sect. 1, A. 31. 31. * Andrews {Complete llecord of the Surgery of the Dattles fought near Vichshurg, December 27///, 28///, 29///, and 3(!///, 18C2, C'liieago, 18G3, p. 32) relates five cases of cranial fmeture with tlie following comments : “ (5f those five fractures two were from bullets penetrating the brain and tlircc from pieces of shell or ohlique bullets. They all died, without exception ; only one was trepanned, and lie without benefit. The general result in military surgery is that gunshot fractures of the cranium arc fatal, and that trepanning is very seldom useful. A few unrecorded cases of recovery, however, came to my knowledge, and it is worthy of notice that these were, without exception, wounds of the anterior lobe of the bruin, which, for some reason. seems to sustain injury with less mortality than any other part.” 320 WOU^’l)S AND IN.TURIP:S of the head CONCLEDED. liivvi't LiiHiteiiaiit Colonel J. G. F. IIolstox, Surgeon U. S. V., 1^’otessor of Anatomy of the Georgetown Medical College, gives the following views of o])erative interference in wounds of the head: *‘I Avill hriidlj state my views of trephining under the thr(‘(‘ heads of primary, intermediary, and subsequent opei’ations. Primary operations are indicat(‘d : 1st. Wliere the scali) is wounded and the subjacent hone hroken in. so as to press upon a portion of the brain that cannot be relieved in any other way; for, in this case, the brain has already sutiered and will sulfer still further injury, if not relieved : commonly, some portions may be picked away by the forceps, so as to render the operation of trephining unnecessary, as by means of the lever the depressed bone may be elevated. In these cases, it has been my practice to remove all depressed bone, a little more or less making no dilference. I have preferred the chisel for such removal, as the sharp edge of the chisel will cut cleaner and with less irritation than the saw, the teeth of which tear the tissues, and give almost as much shock f(»r every tooth, as the chisel and mallet do at every blow. The chisel I have had made by Tiemann, is of the form indicated (Fig. I'i*), the projecting blunt tooth of the cutting edge pressing aside the dura mater and jireventing injury to this structure. *2d. Where a missile, clothing, etc., had entered the brain, and by cautious sounding detected near the orifice. Where they are not so found, I should make no curious explorations of the interior of the cranium, believing that the patient may be more severely hurt by the exploration than by the original injury. 1 should content myself in such cases by ri'inoving all extraneous spiculm of bone and other detrimental matter that may be about the orifice of the w’ound. 3d. Where there is no external wound, but evidently a large compression of bone on the brain. If symptoms of com- pression are gradually there can be no doubt but we should relieve the brain of pressure; in this case, probably blood has been poured out from one of the meningeal arteries. I consider such oj)erutions intermediary as are performed on the patient before he has I’ccovered from the immediate injury inflicted. These operations are by no means as successful as the first, and are generally done in such cases as have not had proper attention. Hut there is one condition, which happens occasionally, where a certain part of the skull has been struck without external wound, llolstoii’s or witliout any sign of compression coining on immediately. After several days, coma begins to manifest itself, and cliisel. liere we have probably to deal with suppuration; which, if not speedily provided with an outlet, will sink deeply. Subsequent operations are such as are performed for the removal of some difficulty left behind, such as epilepsy, paralysis, etc. I liave four times successfully operated on epileptics. The patients all recovered of the operation, and all were cured of the epilepsy. As regatxls success, I would reckon first the subsequent, next the primary, and, lastly, the intermediary operations, which are least successful of all. These are the rules that guide us in private ])ractice, but I found in niy experience in the Army that they did not hold good. The injuries of the head are there so much more violent, that I am inclined to think no intervention to be the safer practice. I believe I have seen more injuries of the head recover Vvithout trephining than with, so that it is an open question with me, wdiether trojdiining should not be either entirely abandoned, or left to the judgment of one specially qualified in the matter. In private practice, the trephine is as successful as (ttlier operative proceedings,’* XoTE. — The following authorities may he consulted on 'Wounds and Injuries of the Head: Andual, Clinique de la Charite^ Tom. Y ] Bauciikt, Dr.v lesions traumatiques dc I'cncephale. Thhe de coneours pour Vagrtjation, I’aris 18G0 ; BaUDE.ns, M. L., Clinique des plaics d'armes d feu, l^aris, 1836; Elements de Chirurgie, Paris, 18 j 8, Tom. 11; llELL, I>., Sgstcni of Surgery, \^aj 1. Ill, 178o; IlERCllOX, Obsercations rcinurquahles dc. fractures du crane. {Bulletin dc la Socidte anatomique, ISOo); IlEUEXGEU DE CARPI, l)c fractura cran/j, l.o2J ; BICIIAT, Menwire sur Ics jdaics de la tele, Paris; DoilX, De renuntiatione vulnerurn, Lipshc, 1711 ; 130IXET, Des signes immediate dc la contusion du cerveau. {Archives gei.eralcs dc medc- ci^e, 5““^ serie, Tom. II ct 111 ,1837); COIUEL, Traite dcs plaics delete, Alcn5 1 Contusions 154 95 45 2 11 24 15 2 Incised Wounds (not sabre) 34 27 5 1 1 24 8 13 3 Aggi'egates 271 167 83 3 18 Sect, n.] GUNSHOT WOUNDS OF THE FACE. 325 Section II. GUNSHOT WOUNDS. Gunshot wounds of the face, comprising those of the external ear, of the eyes, the nose, the cheeks and lips, the buccal cavity with the teeth and tongue, and the jaws, while causing, often, great disfigurements, have not a high ratio of mortality. Secondary haemorrhage, or suppuration and necrosis following the lodgment of balls in the spongy bones of the nasal and supra-maxillary regions, are among the more common causes of fatality in gunshot wounds of the face. Wounds of the auricle presenting little importance, will be summed up in the tabular statement at the end of the chapter. They are more commonly associated with wounds of the neck than of the face. Gunshot injuries of other parts of the face will be considered according to region ; but, as they are so frequently complex, precise classification is impracticable. Gunshot Wounds of the Orbital Region . — These include the wounds of the eyelids, often accompanied by much loss of tissue or by blepharoptosis or ectropion ; or of the eye- brows, frequently followed by amaurosis ; of the globe of the eye or of both eyes, involving traumatic cataract, or staphyloma, or entire evacuation of the humors, and fractures of the bones composing the orbit. We will commence with the most serious cases, those in which both eyes were destroyed : Case. — Private William, V , Co. E, 1st Texas Regiment, was wounded at the battle of Arkansas Post, January lltli, 1863, by a fragment of shell. The missile entered the right side of the face, destroyed both eyes and fractured the left wing of the sphenoid and the petrous portion of the left temporal. He was left on the field until cared for by the Union surgeons. After a light dressing had been placed over the shocking laceration, and anodynes had been administered, he was conveyed to the hospital transport steamer D. A. January, and conveyed to St. Louis and placed in the City Hospital. On admission it was found that the nasal, lachrymal, body of the ethmoid, the turbinated bones, the vomer, and the upper parts of both superior maxillaries had been carried away. Both malar bones were separated and dislocated backward. The soft parts of the face were erysipelatous or sloughing. Inflammation had extended to the brain. He survived this terrible injury thirteen days, death coming to his relief on January 23d, 1863, the day after he entered the hospital at St. Louis. The patient was under the care of Surgeon .John T, Hodgen, U. S. V., who forwarded the specimen, which is represented in the wood-cut (Fig. 1.65), with a memorandum of the case, to the Army Medical Museum. A fracture traverses the body of the sphenoid and petrous ])ortion of the left tenij)oral bone, and a second fissure divides, longitudin.ally, the palatine process of the right superior maxillaiy. The frontal sinuses, which are very large, .are freely exposed, and the cranial cavity is opened through the ethmoid, the opening measuring three-fourths by one-lialf inch. Fig. IS.'j. — Destruction of the eyes and orbital region. Spec. 101 ti, Sect. I, A. M. M. 326 WOUNDS AND INJURIES OF THE FACE, [CnAi>. II. Case. — Sorgeant Jefferson Coates, Co. 11, 7tli IVisconsiii Volunteers, aged 20 years, was w’ouuded at Gettysbui-g,- July 2d, 1863, by a conoidal ball, which entered immediately behind the outer angle of the right eye, passed through the orbital plate at the junctioll of the malar and frontal bones, through the great wing of the si)henoid, and emerged at a ))oint corresponding to the place of entrance, producing a wound not less than an inch and a half in diameter, and tearing away neai'ly the whole of the orbital jdate. The wound of entrance was about half an inch in diameter. He was admitted to the Seminary Hospital, Gettysburg, and, on July 8th, transferred to the Satterloe Hospital, Philadeljdna. When admitted, the tunics of the right eye were hanging out and much tumefied, about as large as a black walnut, and covered witli a mass of slough; there w’as complete eversion of the right lower lid ; otherwise the lids of both eyes were uninjured. The left eye was shrunken, its contents evacuated, and the upper lid was overlapped by the lower. In other respects, with the exception of a slight inflammation, the tunics of this eye were healthy in appearance. In its passage, the ball had apjiarently passed immediately beneath the cribriform plate of the ethmoid, destroying a portion of the latter and the lachrymal bones, and probably severing the optic nerves. There was a profuse discharge of pus from both wounds, and a little through the laceration in the tissues of the left eye. The sense of smell was entirely destroyed. The patient was in a tolerably good condition, but restless ; his appetite was moderate, tongue slightly furred, and pulse about 90. Flaxseed dressings were applied. On July 10th, what appeared to be the external angular process of the frontal bone was taken from the left wound; also several small spiculoe from the right side. On the 11th, the wounds looked better; on the 13th, a small bone, probably from the orbital portion of the great wing of the sphenoid, left side, was extracted. On the 17th, the slough separated entirely from the right eye, which presented a much imj)roved condition. No symptoms of cerebral disturbance had appeared. On the 19th, there was considerable oedema of the left eye, and the inflammation was more marked. On J uly 21st, a thin plate of bone was discharged, from the nose, apj)arently a piece of the perpendicular plate of the ethmoid. Qadema of the upper lid had much increased, though with very little pain. July 24th: the oedema of the left eye was rapidly disappearing under a watery discharge, which tasted salty. July 25th: another small piece of bone came away from the left wound. There was still a profuse discharge ; the right wound was much smaller, and the left was granulating finely. Night sweats occurring, quinine in solution with aromatic sulphuric acid was given every three hours. The right eye was less congested, and tlie protruding portion was rapidly disappearing under the action of sulphate of copper in crystal. The patient was in good spirits. August 1st: the discharge from the left eye was but small, and healthy granulations were springing up ; the discharge from the nose, and the night sweats had ceased. August 8th : the wound of entrance had healed ; that of exit was rapidly closing. The patient was discharged on September 22d, 1864, and pensioned. Acting Assistant Surgeon M. J. Grier, 'who reports the case, states that after the insertion of the artificial eyes there will be very little deformity. Case. — Private William Brown, Co. D, 119th Pennsylvania Volunteers, aged 24 years, was wounded at Cold Harbor, Virginia, June, 1864, by a conoidal ball, which entered the light temple two inches from the orbit, and emerged through the right eyeball. He was admitted to hospital 1st division, Sixth Corps; on June 11th, transfeiTcd to Campbell Hospit.al, Washington, and on .July 23d, sent to Satterlee Hospital, rvhence he was discharged June 28th, 1865. The right eye was totally destroyed, and the sight of the left eye was lost. In IMarch, 1868, he was a pensioner at .$25 per month, his disability being rated total and permanent. Dr. .T. A. McAi-thur reports that Brown was under his care at Soldiers’ Home, Philadelphia, until January 27th, 1869, when he died of phthisis puhnonalis. At the time of his death, he suffered from total blindness. Case. — Priv.ate Charles C , Co. H, 30th North Carolina Regiment, aged 30 yeai-s, received at the b.attle of the Wilderness, May 7, 1864, a gunshot wound of the fiice. The missile entered the left temple, passing obliquely anteriorly, and emerging one inch below the left eye, severely fracturing and comminuting the sujierior maxilla, and completely destroying the nasal bones. He was among the captured wounded sent on hospital transports to Washington, and on May 14th was admitted to Carver Hospit.al. He was very low, and in a com.atose state, requiring considerable exei-tion to arouse him sufliciently to partake of food and stimulants, which were freely administered. He took a quart of milk punch daily. Detei'gcnt lotions were applied to the Avound. The contents of the left orbit were evacuated, and the vision was destroyed in the right eye. Inllammation gradually extended to the brain; but without any very violent symptoms. The patient survived twenty days, death resulting May 27th, 1864. Acting Assistant Surgeon J. E. Winants reported the ease and sent the specimen, figured in the wood-cut (Fig. 156), to the Army Medical Museum. The right malar, the bodies of both superior maxillaries, both lachrymal bones, the body of the ethmoid, with the turbinated bones, the left great ala of the sphenoid, and the left external angular process of the frontal with the orbital plate have been c.arried aw.ay. The left parietal is fissured from the anterior inferior angle to the parietal emiuence. The left ])alate bone is fractured across, tbe sphenoid cells are exposed, and the cranial cavity is freely opened. The edges of d.e fractured bones are slightly necrosed ami shoev traces of an attempt at repair. Camekon, .Joseph, Sergeant, Co. A, 13th Ohio Cavalry, aged 25 3 'ears. Gunshot fracture of facial bones. Conoidal ball enteriKl one-half inch below external canthus of right eye, ]).asscd under the nose, and emerged .at the outer angle of left ej-e, carrying awaj" a considerable portion of orbital plate. Petersburg, Virginia, July 30th, 1864. Conijdete loss of sight in both ej’es. Discharged Januaiy 2d, 1865, and pensioned. Sect. II.] GUNSHOT WOUNDS OF THE EYES. 327 .Case. — Private John T. Cole, Co. A, lOtli Veiinont Volunteers, aged 24 years, was wounded at Petersburg, April 2d, 186.U, by a colloidal ball, which entered just above the left zygoma, passed through the orbit, and emerged through the outer and upper portion of the light orbital structure, destroying lioth eyes. He was, on the following da}', admitted to the depot field hospital at City Point ; on April 7th, sent to the Lincoln Ilosjiital, AVashington, and, on May 2(5th, transferred to the Sloan Hospital, Montpelier, Vermont. At this time the wound of entrance had healed and the general health of the patient was good, but lying on the left side would cause headache ; the sense of smell was entirely destroyed. Cold water dressings were applied ; during the treatment, small pieces of bone were taken from the wound of entrance. Otherwise the case progressed well, and, on June 12th, 1865, Cole was discharged from service and pensioned at $25 per month. Case. — Private William II. Davis, Co. C, 51st Ohio Volunteers, aged 22 years, was wounded near Kenesaw Mountain, Georgia, June 20th, 1864, by a conoidal ball, which entered the inner canthus of the right eye, passed through the base of the nose and left eye and emerged at the left temple, destroying both eyes. He was admitted to the hospital of the 2d brigade, 3d division. Fourth Corps; on June 25th, sent to field hospital at Chattanooga, Tennessee; on July 11th, to Hospital No. 8, Nash- ville ; on July 22d, to Totten Hospital, Louisville, Kentucky, and on August 3d, to Camp Chase, Ohio, where he was discharged from the service October 27th, 1864, and pensioned. Case. — Sergeant Philip Gottman, Co. E, 74tli New York Volunteers, received, at the battle of Gettysburg, July 2d, 1863, a gunshot wound of the left temple, the missile destroying in its course both eyes. He also received, in the same engagement, two wounds of the left thigh and one of the right. He was admitted to the field hospital, and on July 8th, sent to the Jarvis Hospital, Baltimore, where he was discharged the service December 15th, 1863. The wounds had all healed, but the patient was totally blind. He was, in March, 1868, a pensioner at $25 per month. Case. — Privmte H. C. Green, Co. F, 2d New York Cavalry, was, on January 28th, 1864, admitted to regimental hospital, with a gunshot fracture of the temporal bone. A conoidal ball entered upon the right side of the head, about one and a half ipches from the angle of the right eye, and emerged near the outer angle of the left eye. He was, on June 29th, left in the hands of the enemy, but was afterward exchanged, and on October 5th, 1864, discharged from the service. Examiner Cyrus Porter, M. D., reports, October 5th, 1834, that he is entirely blind. . Case. — Private John Miller, Co. I, 7th New York Heavy Artillery, aged 42 years, was wounded at Hatcher’s Run, April 2d, 1865, by a conoidal ball, which entered the anterior part of the right temporal region, traversed both orbits, and emerged at a corresponding point on the oi)posite side of the head. He was sent to the hospital at Fort Monroe on April 13th, and on July 15th, was transferred to the Ira Harris Hospital, Albany, and discharged November 30th, 1865, and pensioned. He was totally blind, and the orbits were filled with profuse granulations of a flabby, spongy character. There was slight ectropion of both eyelids, the lashes I'esting against the contents of the sockets of the eyes, giving rise to considerable irritation. Vide Card Photographs, Vol. VI, page 9. Case. — Private Elisha R , Co. F, 67th Indiana Volunteers, received, at the battle of Carrion Crow Bayou, Louisiana, November 3d, 1863, a gunshot compound comminuted fracture of the facial bones. The missile entered posterior to the right external angular process of the frontal bone, passed forward and inward, destroying the right eye, and carried away the nasal and lachrymal and the orbital processes of the superior maxilla, and emerged through the internal canthus of the left eye. He was, on November 9th, admitted to the University Hospital, New Orleans. Simple dressings were applied to the wound. The patient died November 22d, 1833. The post mortem examination showed an abscess in the right anterior lobe of the cerebrum. The lesions about the orbit are represented in the adjacent wood-cut (Fig. 157). The orbital poitions of the right malar and upper maxilla are wanting, and the greater part of the turbinated bones are comminuted and removed. The frontal sinuses and sphenoidal cells are freely opened. The specimen and notes of the case were con- tributed byatient was discharged the service on December 19th, 1832, and pensioned. Subsequent information avers that the patient’s lower jaw was anchylos. 32, Snrrj. Scries). The patient was discharged from service and l)ensioned April 26tb, 1865. In 1887, Pension Examiner G. W. Avery, reported that this pensioner continued to suffer greatly, and that the very unple.asant deformity induced by bis wound, made it impracticable for him to obtain employment. Thus bis mutilation was a doubly cruel one. Case. — Private Jonas Err.ay, Co. II, lOtb New York Cavalry, aged 23 years, was wounded near Sbepberdstown, July 16tb, 1863, by a conoidal musket ball, which entered the frontal bone one inch above the right superciliary ridge, near the median line, passed downward and outward, and lodged in the superior maxillary bone. Insensibility, of four or five hours’ duration, followed the injury. The patient remained at the field hospital until the 30th, and was then conveyed to Hospital No. 1, at Frederick. The wound had nearly cicatrized, but the pulsations of the brain were plainly visible; the sight of the right eye was destroyed, and sensibility on that side of the face was lost. On the 2d of August, pain in the head supervened, due, in a measure, to the irritation produced by the injured eye, with which, moreover, the sound eye sympathized. The pain continuing unabated. Acting Assistant Surgeon John H. Bartholf extirpated, on August 11th, the right organ of vision. The headache still continued until the 20th, and giddiness was produced by the least exertion; the power of feeling and of smell in the right nostril had, by this time, somewhat improved. On the 28th of the month, the socket of the right eye was granulating healthily, and there was only little discharge from the original wound. On October 1st, the wound had so far healed that the pulsations of the brain ceased to be visible. On November 3d, the missile was detected behind the last mohar tooth and extracted by the dressing forceps. The sensibility of the fifth pair of nerves was now restored but the mobility of the jaw remained limited. The patient was discharged from service on November 16th, 1833. The pathological specimen. No. 3970, Sect. I, A. M. M., exhibits the cornea and lens of the right eye. The vitreous humor in great part remains opaque and of a yellowish white color. A collection of clotted blood fills the anteiior portion of the cavity, protruding through the iris. The case is reported by the operator. Acting Assistant Surgeon John H. Bai'tholf. Pension Examiner J. K. Stanchfield, M. D., reports, December 21st, 1863, that the opening in the forehead is not yet closed and sometimes discharges. Case. — Colonel Patrick K. Guiney, 9th Massachusetts Volunteers, was wounded at the battle of the Wilderness, May 5th, 1864, by a conoidal musket ball, which entered just above tlie inner angle of the left eye and passed across the orbit and behind the malar bone and zygoma to near the ear, where it lodged. The missile fissured the frontal bone at the inner extremity of the supra-orbital ridge quite deeply, and must have penetrated the frontal sinus. The eye was destroyed, and, in removing the ball, Steno’s duct was severed. He was admitted to the hospital of the 1st division. Fifth Corps, and, on Iilay 12th, sent to Wash- ington, where he received a leave of absence on May 14th, 1864. He was mustered out of service on .Tune 21st, 1884, and pensioned. For a year after the reception of the injury a s.alivary fistula continued to discharge, when one day the discharge ceased suddenly with a sensation of an electric thrill. No discharge recurred, but the thrill is renewed whenever, in shaving, the razor touches the cicatrix. Although the wound was not immediately connected with the brain it has affected it in its functions. He is unable to concentrate his thoughts for any length of time without suffering from dizziness and confusion of ideas, the dizziness becoming so decided at times, as to neces.sitate the grasping of objects near him for support. Since the war, w’hile serving as Assistant District Attorney at Boston, he has been obliged to bathe his head, during the session of the court, to enable him to attend to his duty. He is now, February 1st, 1870, wholly unfitted to attend to his duties by reason of pneumo-hydro- thorax. The case is reported by Dr. P. A. O’Connell, late Surgeon 9th Massachusetts Volunteers. Case. — Private John F. Lord, Co. I, 1st iMaine Cavalry, aged 24 jmars, was wounded at the battle of the Wilderness, May 6th, 1884, by a conoidal musket ball, which entered the left eye and lodged at the left temple. He was at once admitted to the hospital of the 2d division, Cavalry Corps, thence conveyed to Washington, and admitted, on the 11th, into the Emory Hospital, where the missile was extracted and the wound dressed in the usual manner. On IMay 16th, lie was transferred to the De Camp Hospital, New York, and thence, on June 2d, sent to the Cony Hospital at Augusta, klaine. On February 16th, 1835, he was discharged from service and jicnsioned. Examiner John L. Allen, M. D., reports, October 22d, 1866, that there is a depression of the skull over the left eye, resulting in paralysis of left side and upper and lower extremities. He c.an but just drag himself about. Case. — Private Jade Kemp, Texas Partisan Eangors, aged 35 years, was wounded at La Fourche Crossings, Louisiana, June 21st, 1883, by a conoidal ball passing from right to left obliquely and backward, carrying away the nose from root to the end of the osseous portion, just missing the right eye and destroying the left. The ball emerged near the outer angle of the left orbit. Portions of brain tissue escaped. Cold w’ater dressings were applied, and opiates and stimulants given. Six weeks after the reception of the injuryho was returned to the hands of tlie Confederates. He had been able to walk about the ward for two weeks; the wound tvas doing well^ giving promise of entire recovery. The case is reported by Surgeon W. N. Trowbridge, 23d Connecticut Volunteers. Case. — Private George Guptill, Co. K, 29th Maine Volunteers, aged 24 years, was wounded at the battle of Cedar Creek, October 19th, 1884, by a ball which passed through the upper lid of the left eye, penetrated the orbital i)late and lodged, evacu- ating the humors of the globe. He was sent, on October 23d, to Satterlee Hospital, Philadelphia. Strict attention wms paid to his diet, and his room was darkened. Several loose pieces of bone were removed. No attempt was made to find the ball. The patient’s pulse was decidedly cerebral, slow and irregular. Erysipelas supervened. In the beginning of November, he com- plained of p.ain and twitchings of the muscles of the feet and occasional headache. Toward the end of November, he began to improve, and was discharged from the service on January 7th, 1865. The wound, which had been kept open as long as discharge issued, had closed, and he was, to all a))pearances, well. Iii July, 1868, the Pension Commissioner stated that Guptill was a pensioner at $8 per month, his disability being rated total and permanent. 'I'lie case is reported by Surgeon I. I. Hayes, U. S. V. Sect. II.] GUNSHOT WOUNDS OP THE EYE. 331 Case. — Private James Neilson, Co. H, llStli Pennsylvania Volunteers, aged 28 years, was wounded in an engagement at Slicplierdstown Ford, Maryland, September 20tb, 18G2, by a conoidal musket ball, wbicli entered the mastoid process of the right temporal bone, and emerged at the external canthus of the left eye, destroying the organ, and tearing the lower lid so that it hung down over the face, even with the tip of the nose. He lay on the field in an insensible condition from morning until night, when he was taken to the Fifth Corps hospit.al. Thence ho was transferred, on the 27th, to the Broad and Cherry Streets Hos- pital, Philadelphia, and on October 3d, to the Cuyler Hospital, at Germantown. When the inflammation had subsided, Acting Assistant Surgeon, J. M. Leedom, stitched the lower eyelid with a lead suture. It soon united, and relieved the deformity very much. The patient being subject to fainting fits, almost epileptic in their character, bromide of potassium was administered, and after a few weeks the fits ceased to occur. He was transferred to the Veteran Eeserve Corps on May 12th, 1864. In November, 1867, Neilson was able to follow his usual vocation of carpet weaving. There was a sero-purulent discharge from the eye, especially in d.amp weather, and he was still subject to liiinting spells, when under any undue emotion, or when exposed to great heat. Tlie reporter. Dr. Leedom, tried to introduce an artificial eye, but whenever it was inserted, a fainting spell was brought on. Case. — Corporal John H. Seldon, Co. IT, 21st Connecticut Volunteers, aged 24 years, was wounded at Petersburg, July 30th, 1864, by a conoidal musket ball, which entered the left temporal region, passed through the left orbit, and emerged through the right nostril. The left eye was entirely destroyed. He was taken to the hospital of the 1st division. Eighteenth Corps, and thence conveyed to Washington, and placed in the Campbell Hospital. On August 28th, he was sent to the Ladies' Home, New York, where he remained under treatment until November 30th, when he was transferred to the Knight Hospital, at New Haven. He was discharged fi’om service February 10th, 1865. In 1869 he was a pensioner, his disability being rated as total. Mastica- tion was difficult, his sense of smell was affected, and, beside the loss of his left eye, vision in the right eye was impaired. His mind had become so affected as to unfit him for mental application, and he complained of a dull pain in the head. t CASE. — Private Thomas Thatcher, Co. K, 12th Ohio Volunteers, was wounded at Bull Run Bridge, August 27th, 1862, by a round musket ball, which entered the inner angle of the right eye, destroying that organ, passed obliquely downward and lodged at the angle of the left inferior maxilla. He was admitted to the Mansion House Hospital, Alexandria, where the ball was removed. The patient recovered and was discharged December 24th, 1862. The specimen and history of the case were contributed to the FIG. 158.— Round Army Medical Museum by Surgeon J. E. Summers, U. S. A. The ball, figured in the wood-cut (Fig. 158), ™fs* of* fnSal bones roughened and jagged, .and there are bony particles embedded in the furrows. No application from this 4 t appears upon the Pension Records, hence it may be hoped that his recovery was so complete that he did jl. M. ’ ’ not require assistance. Case. — Priv.ate George I’hompson, Co. F, 6th Missouri Volunteers, was wounded at Arkansas Post, January 11th, 1863, by a pistol ball, which entered the inner portion of the right supra-orbital ridge, near the base of the nose, and passing outward and slightly downward, fractured the orbital plate, and lodged in the frontal sinus. He was conveyed by ste.amer to Memphis, and placed in Hospital No. 3, on .January 23d. At the dressing of the wound, the course of the missile was tr.aced along the fracture as far as the bottom of the orbit, beyond which it was not considered prudent to explore. The globe of the eye was disorg.anized and destroyed. For a considerable time inflammation ran very high, and the pain was exceedingly severe. The swelling, however, after two or three weeks, gradually subsided. The wound remained very painful afterwiird, and renewed treatment was nocessaiy to allay the pain. Extirpation of the disorganized eyeball was considered at this time, but the operation was rejected. Acting Assistant Surgeon Thomas T. Smiley, in his comments upon the case, declares his conviction that this should have been done, as thereby the missile, and ]irobably splinters of bone at the bottom of the orbit as well, might hav'e been removed. The patient was discharged from service on April 3d, 1863, though not entirely cured, yet still able to travel. In March, 1869, Examining Surgeon W. \V. Potter reports this pensioners disability as three-fourths and permanent. Case. — Colonel J.ames Washburn, 116th Ohio Volunteers, was wounded near Snicker’s Ferry, .July 18th, 1864, by a conoidal ball, which entered the comer of the left eye and emerged from below the right oar. The right side became paralyzed and the face grew di.storted from contraction of the facial muscles. The left eye was entirely destroyed. He was mustered out on July 5th, 1865, and pensioned, his disability being rated total and i)ermancnt. Case. — Private John A. Lasell, Co. C, 60tli New York Volunteers, aged 24 years, received, at the battle of Gettysburg, ’ .July, 1863, a gunshot wound of the eye and head. He was conveyed to the field hospital, where ho remained until July 10th, when ho was transferred to New York, entering McDougall Ho.spital on the 12th. Ho died August 23d, 1864. Assistant Surgeon H. M. Sprague, U. S. A., reports the case. Case. — Private S. C. Kennin'iham,, Co. IC, 12th Virginia Regiment, received, on July 15th, 1863, a gunshot wound of the eye. He was admitted to No. 1 Hospital ;it Richmond, soon after the reception of the injury, and died the day of his admission. Case. — Private M. JF. Sexton, Co. C, 13th South Carolina Rc'giment, received a gunshot wound of the left eye by a conoidal ball. He was admitted to the Jackson Hospital at Richmond, on July 29th, 1884, where he died on September 30th, 1864. Ca.se. — Private A. B. Wilson, Co. F, 10th Temiessee Volunteers, aged 29 years, while being taken, iii a state of intoxica- tion, to the guard-house at Fort Gillem, near Nashville, on Se])t<'mber 20th, 1864, was accidentally wounded by a conoidid musket ball, .at the angle of the nasal and malar bones, three-fom-ths of an inch below the inner canthus of tlie left eye, jiassed dee]ily beneath the nasal bones, upward, outward, and backward, and (‘merged at tlie junction of the I'rontal and the right jiarietal bones, two inches from the median line. Ho was immediately conveyed to Hosjdtal No. 8, Nashville, in an unconscious state. 'J'he brain substance and bloody serum issued from the wound of exit, as well as entmnee. The right eye was destroyed ; its njiiier lid being nearly severed from it.s connoclions. The usual dressings were ajiplied, and the treatment in the main was ex))ectant. 332 WOUNDS AND INJURIES OF THE FACE [Chap. II. During the day the pulse rose from 7G to 80, the respirations numbered 16, and consciousness was partially restored. On the22d he had become fully conscious, and complained of pain in the head. The next morning the pulse was 96, and the respirations 20. He was still conscious, though mental effort was dull; but shortly afterwai'd he sank into a state of coma. The brain sub- stance now exuded freely. He died on September 24th, 1864. At the autopsy, on dividing the integuments between the wounds of entrance and exit, the nasal and frontal bones were found badly fractured, and several large fragments of the frontal were detached. Further examination disclosed extensive disorganization of the encephalon. Case. — Private Louis W , Co. K, 10th Vermont Volunteers, aged 33 years, was wounded at tl;e battle of Cold Harbor, Virginia, June 1st, 1864, by a conoidal musket ball, which entered the frontal bone above the nasal eminence, carried away both sinuses and a portion of the left orbital ()late, destroyed the left eye, and escaped near the angle of the left I'amus of the lower jaw. He was conveyed to Washington, and admitted, on the 9th, into the Lincoln Hospital. Death occurred June 16th, 1864. At the autopsy, an opening was found in the frontal sinus, measuring three-fourths by half an inch, through which a grayish slough, involving the brain, and exhaling a gangrenous odor, was observed. Upon the removal of the frontal portion of the calvarium to a level with the orbital region, a fragment of the wall of the sinus was found, adherent to the dura mater, beneath which membrane extravasation of venous blood existed. There was also a general enlargement of the veins of the cerebrum. The optic commissure and nei've were found lacerated, and the tuber cinereum in a sloughing condition. Some twelve ounces of venous blood exuded from the meningeal vein, especially from several points along the falx cerebri and falx cerebelli. The heart was fatty on the right side, but the lungs and other organs were perfectly sound. The pathological specimen is No. 2574, Sect. I, A. iM. M, and was contributed, with its history, by Assistant Surgeon J. C. McKee, U. S. A. Abbott, Haklin, Private, Co. F, 77th New York Volunteers, aged 24 years. Spottsylvania, May 10th, 1864. Fracture of edge of left orbital arch and laceration of integuments of eyebrow. Left eye destroyed and sight of right eye impaired. Washington, Philadelphia, New York, and Albany hospitals ; transferred to Veteran Reserve Corps. Discharged August 4th, 1865; pensioned. Ackerly, D.ARIUS, Corporal, Co. K, 19th Michigan Volunteers. Thompson’s Station, Tennessee, March 5th, 1863. Bridge of the nose, right eye, and a portion of the temporal bone carried away by a conoidal ball ; also wound of left thigh. Taken prisoner, exchanged, and treated at Annapolis and Camp Chase. Discharged October 23d, 1863. Adajis, Erastus, Private, Co. M, 1st Maine Heavy Artillery, aged 41 years. Petersburg, June 18th, 1864. Fracture of left side of frontal bone. City Point, Rhode Island, and Maine hospitals. Total loss of right and partial loss of left eye. Dis- charged July 14th, 1865, and pensioned. Austin, L., Private, Co. A, 24th New York Cavalry, .aged 21 years. Petersburg, June 18th, 1864. Conoidal ball entered above the left eye and lodged under the right ear. Field, Washington, and Philadelphia hospit.als. Left eye destroyed. Dis- charged June 14th, 1885, and pensioned. Adams, George, Private, Co. I, 9th New Hampshire Volunteers. Petersburg, July 25tlt, 1864. Gunshot wound of face. Admitted to Emory Hospital, Washington, August 1st, 1864. Removal of spicula of bone. Discharged November 20th, 1864, with loss of right eye and partial loss of sight of left eye, and pensioned. Adams, Thomas, Private, Co. K, 13th Ark.ansas Regiment, aged 24 years. Franklin, Tennessee, November 30th, 1864. Gunshot fr.acture of superior maxilla; eye destroyed. Sent to Provost Marshal June 9th, 1865. Ames, John F., Private, Co. G, 91st New York Volunteers, .aged 24 years. Gravelly Run, Virginia, March 21st, 1865. Gunshot fracture of left nasal and superior maxillary bones. Entire destruction of left eye. Ligation of left common carotid artery. Discharged July 3d, 1865, and pensioned. A. M. M. Photograph Series, No. 283. Abbott, Joel, Private, Co. D, 12tli New Jersey Volunteers. Chancellorsville, May 3d, 1863. Gunshot wound, fracturing orbital plate and destroj'ing left eye. Sight of right eye sympathetically impaired. Washington, Delaware, and New Jersey hospitals. Discharged December 11th, 1863, and pensioned. Board.m.vn, Mok.vnd, Private, Co. B, 9th Illinois Volunteers, aged 41 years. Shiloh, April 6th, 1862. Fiacture of m.alar and frontal bones and destruction of eye. City hospital, St. Louis. Great dishgur.ation. Discharged September 23d, 1882. Bradley, J. C., Private, Co. G, 14th Alabama Regiment. Destruction of left eye .and audition, left side, by gunshot missile. Treated in Richmond hospitals, and furloughed July 19th, 1864. B)-itt, J. J., Sergeant, Co. D, 43d North C.arolina Regiment, aged 27 years. Winchester, September 19th, 1864. Destruc- tion of vision of left eye by a fragment of shell. Tiiken prisoner and treated in field and Baltimore hosjntals. Sent to Provost Marshal for exchange April 8th, 1885. Burke, Albert J., Corporal, Co. I, 117th New York Volunteers, aged 28 years. Petersburg, July 9th, 1864. Destruc- tion of right eye by explosion of shell. Fort Monroe, Rhode Island, and New York hospitals. Deafness of right ear. Discharged March 1st, 1885, and pensioned. Bur.meister, Henry, Sergeant, Co. A, 9th Illinois Volunteers. Shiloh, April 6th, 1862. Fracture of right orbital arch and destruction of left eye. Quincy, Illinois, hospital. Exfoli.ation of bone. Repulsive deformity. Discharged September 22d, 1862, and pensioned. Butkr, IF. C., Sergeant, Co. C, 15th Virginia Regiment. Gunshot wound through right oihit; also wound of thigh. How.ard Grove Hospital, Richmond. Furloughed June 29th, 1864. Byrne, Dudley’, 1‘rivate, Co. A, 88th New York Volunteers. Antietam, September 17th, 1862. Loss of right eye. Philadelphia hospital. Discharged Januaiy 5th, 1863, and ])ensioned. There was great defoiaurty, and the sense of smelling was gone. Neuralgic trouble also existed. Barksdale, llezekiah I)., Private, Co. E, 6th Arkansas Regiment. Fracture of right orbital ridge; eye destroyed. Admitted to Confederate hospital, Dalton, Georgia. Tlie result of the case is not recorded. Sect. II.] GUNSHOT WOUNDS OF THE EYE. 333 Balders, Charles, Corporal, Co. K, 134th New York Volunteers, aged 31 years. Gettysburg, July 1st, 18G3. Fracture of frontal bone over left eye by conoidal ball ; eye destroyed ; also wound of right arm. Pennsylvania ami New York hospitals. Discharged January 31st, 1865, and pensioned. Belcher, Char^,es, Private, Co. K, 6th Pennsylvania Volunteers. Antietain, September 17th, 1862. Fracture of frontal bone. Corps and W'ashington hospitals. Destruction of left eye and partial deafness of left ear. Discharged November 3d, 1862, and pensioned. Blxby, Philip, Private, Co. E, 92d New York Volunteers. Fair Oaks, May Slst, 1862. Fracture of fi-ontal bone above left orbit; missile lodged, destroying sight. Field and New York hospitals. Discharged October 29th, 1862. Bradden, Isaac H., Private, Co. B, 24th Indiana Volunteers, aged 21 years. Champion Hills, Mississippi, May 16th, 1863. Gunshot wound; missile entered at the external canthus of left eye, passed under the bones, and emerged through the internal ear, fracturing orbital plate of malar bone, destroying eye, and causing entire deafness of ear. Memphis, St. Louis, and Madison hospitals. Discharged July 26th, 1864, and pensioned. Great deformity. Browist, John, Private, Co. G, 2d Delaware Volunteers. Antietam, Maryland, September 17th, 1862. Gunshot wound of face. Conoidal ball entered right ear, and emerged from right eye, completely destroying the globe. Admitted to Satterlee Hospital, Philadelphia, October 29th. The lower lid became everted. Discharged January 20th, 1863, and pensioned. Bennett, IF. B., Co. B, 49th North Carolina Regiment. Gunshot injury of bones of face and destruction of right eye. Admitted to Chimborazo Hospital, Richmond, Virginia. Furloughed for sixty days. Bechet, J. Z., a Confederate soldier. Gunshot fracture of bones of face. Missile entered arch of nose and passed through right orbit, destroying the eye. Admitted to Howard Grove Hospital, Richmond, Virginia. Furloughed for sixty days, July 14th, 1864. Boxxell, Charles, Private, Co. A, 64th Illinois Volunteers, aged 18 years. Gunshot injury of occipital and frontal bones, with destruction of right eye. Nashville, Tennessee, December 18th, 1864. Admitted to McDougall Hospital, New York, January 12th, 1865. Discharged June 26th, 1865, and pensioned. Barxes, Thomas G., Private, Co. H, 67th New York Volunteers, aged 21 years. Conoidal ball entered frontal bone to left of median line, traversed the sinus, and lodged in nasal foramen ; also wound of left thigh, two inches above knee. Admitted to Patent Office Hospital, Washington, December 11th, 1862; sent to Ladies’ Home Hospital, New York, January, 1863. Aqueous humor of left eye ran out. Discharged May 18th, 1863. He is not a pensioner. Baggott, \V. H., Private, Co. K, 3d Tennessee Cavalry, aged 18 years. Conoidal ball entered' and destroyed left eye, and emerged at mner angle of right eye. Pulaski, Georgia, September 25th, 1864. Discharged July 13th, 1865, and pensioned. Ballstetter, Charles, Co. E, 74th Pennsylvania Volunteers. Conoidal ball entered near left ear, passed through lower jaw, obliquely through the upper, and destroyed the right eye. Bull Run, Virginia, August 29th, 1862. Discharged February 24th, 1863. He is not a pensioner. Bolton, S^amuel M., Private, Co. D, 11th Maine Volunteers, aged 32 years. Missile, a buckshot, penetrated and destroyed the right eyeball. Bermuda Hundred, June 2d, 1864. Ball removed. Discharged April 21st, 1865, and pensioned. Berg, John, Pilvate, Co. A, 117th New York Volunteers, aged 25 years. Gunshot wound of face. Missile carried away right eye. Fort Fisher, North Carolina, January 15th, 1865. Discharged June 22d, 1865, and pensioned. Carpenter, J. D., Private, Co. M, 16th North Carolina Regiment. Chancellorsville, May 3d, 1863. Fracture of cranium, with loss of vision of left eye. Treated in Richmond hospital until June 18th, 1863, when he was furloughed. Clifton, Perry C., Private, Co. B, 20th Indiana Volunteers, aged 40 years. Bull Run, August 29th, 1862. Fracture of temporal and orbital bones and destruction of left eye. Alexandria hospital. Discharged October 31st, 1862, and pensioned. Vision of right eye impaired. Great deformity. Clinton, Thomas, Private, Co. K, 1st United States Artillery, aged 25 years. Accidentally shot March 9th, 1865. Loss of left eye. Field and Frederick hosjiitals. Vision of light eye impaired. Discharged July 22d, 1865, and pensioned. Craig, James A., Private, Co. D, 198th Pennsylvania, aged 44 years. Gravelly Run, March 29th, 1865. Fracture of temporal bone and bones of face ; right eye destroyed. Field, Washington, and Philadeljihia hospitals. Impaired vision of left eye. Discharged July 27th, 1865, and pensioned. Crew, John, Private, Co. F, 12th United States Infantry. Before Richmond, latter part of June, 1862. Fracture of cranium and loss of right eye by conoidal ball. Baltimore hospitals. Discharged December 30th, 1862, and pensioned. Coffman, H. C., Private, Co. F, 3d Arkansas Regiment, aged 19 years. Fracture of skull and loss of the left eye. Vision of right eye impaired. Petersburg hospital. Recovered. Cole, Charles, Corporal,_ Co. A, 103d Ohio Volunteers, aged 22 years. Rcsaca, May 14th, 1864. Fracture of orbital and frontal processes of malar and anterior and middle roots of zygomatic process of temporal ; vision and audition of left side destroyed. Field, Chattanooga, and Nashville hospitals. Discharged February 25th, 1865, and pensioned. COLGROVE, Franklin, Private, Co. H, 10th Illinois Volunteers, aged 31 years. Bcntonville, March 21st, 1865. Fracture of light temporal and destruction of light eye by conoidal ball. Field, New Berne, New York, and Madison hospitals. Dis- charged May 26th, 1865, and pensioned. COPENSPIRE, Ch.uiles, Private, Co. K, 60th Now York Volunteers, aged 20 years. Winchester, September 19th, 1864. Fracture of left temporal and upper jaw ; left eye destroyed. Field and Philadelphia hospitals. Several pieces of upper jaw removed. Discharged June 2d, 1885, and pensioned. 334 WOUNDS AND INJURIES OF THE FACE, [Chap. II. Chase, Reuben, Private, Co. A, 37th Massachusetts Volunteers, aged 24 years. Shell wound, fracturing maxillary and malar bones, causing total loss of right eye. HatcheFs Run, Virginia, February 7th, 1865. Admitted to Campbell Hospital, Washington, March 19th, 1865. Sent to Satterlee Hospital, Philadelphia, April 6th. Discharged July 6th, 1865, and pensioned. Curd, J. L., Private, Co. H, 49th Virginia Regiment, aged 22 years. Gunshot wound of face. Ball entered near external angle of left eye, destroying the eye, passed through superior maxilla, and emerged below outer corner of right eye, impairing its usefulness. Seven Pines, Virginia, July, 1862. Retired from the service. Chisholm, John W., Private, Co. D, 46th Pennsylvania Volunteers, aged 21 years. Conoidal ball entered at outer angle of left eye, destroyed the eyeball, and emerged on right side, one inch below the eye. Peach Tree Creek, July 20th, 1864. Discharged July 27th, 1865. He is not a pensioner. Ceawley, David, Private, Co. C, 107th New York Volunteers, aged 23 years. Conoidal ball struck nasal bone, and passed through left eye. Chancellorsville, Virginia, May 3d, 1863. Discharged August 29th, 1864. Total loss of left eye, and I)artial loss of sight of right eye. He is not a pensioner. Caetee, John W., Lieutenant, Co. A, 23d U. S. Colored Troops, aged 42 years. Gunshot wound of face. Missile entered outer angle of left eye, fractured nasal bones, and emerged from inner angle of right eye. The left eye was destroyed. Petersbui'g, Virginia, July 30th, 1864. Discharged February 6th, 1865, and pensioned. Connolly, Beenaed, Private, Co. B, 65th New York Volunteers, aged 22 years. Gunshot fracture of malar bone, with loss of use of right eye, and sympathetic aft'ection of the left eye. Cedar Creek, Virginia, October 19th, 1864. Can but partially open the mouth. Discharged July 24th, 1865, and pensioned. Caeutiiees, William L., Private, Co. G, 2d West Virginia Volunteers, aged 25 years. Conoidal ball entered left antrum, and emerged through the left orbit, tlisorganizing the eye. Farmville, Virginia, April 6th, 1865. Discharged July 26th, 1865, and pensioned. Ceaey, Peospee, Private, Co. F, 13th Michigan Volunteers, aged 41 years. Gunshot fracture of nasal bone; missile destroying right eye. Bentonville, North Carolina, March 19th, 1865. Discharged July 26th, 1865, and pensioned. Castelvecchio, Raeaele, Sergeant, Co. A, 39th New York Volunteers. Gunshot fracture of superior maxilla. Sight of right eye destroyed. Bristow Station, Virginia, October 15th, 1863. Recovered, and was discharged and pensioned. Dance, Chaeles W., Private, Co. G, 66th New York Volunteers. Antietam, September 17th, 1862. Destruction of left eye by conoidal ball. Field and Philadelphia hospitals. Discharged November 28th, 1862, and pensioned. Daniels, Asa B., Private, Co. F, 5th Michigan Volunteers, aged 17 years. HatcheFs Run, March 25th, 1865. Fracture and depression of frontal bone by conoidal ball ; right eye destroyed. Field, Washington, and Philadelphia hospitals. Discharged June 9th, 1865, and died December 13th, 1865. Davis, Cyeus, Private, Co. G, 9th New York Cavalry, aged 22 years. Smithfield, Virginia, August 29th, 1864. Wound of right temporal region ; right eye destroyed. Sandy Hook, Annapolis, and Buffalo hospitals. Discharged July 17th, 1865, and pensioned. Will probably become totally blind. Dennis, Geoege W., Corporal, Co. E, 90th Pennsylvania Volunteers. Fredericksburg, December 13th, 1862. Left eye destroyed. Field, Washington, and Philadelphia hospitals. Discharged May 15th, 1863, and pensioned. Dingee, Nathan, Private, Co. D, 107th Pennsylvania Volunteers, aged 21 years. Gettysburg, July 1st, 1863. Loss of left eye. Camp Letterman and Philadelphia hospitals. Discharged May 8th, 1865, and pensioned. Donovan, John E., Private, Co. D, 2d Wisconsin Volunteers, aged 26 years. Bull Run, July 21st, 1861. Fracture of external part of left orbit; also flesh wounds of right leg, left heel, chest, i-ight arm, and shoulder and right forearm. Taken prisoner, exchanged, and treated in Washington and New York hospitals. Vision of left eye and hearing of right ear entirely lost. Headache, giddiness, and weakness. Discharged October 19th, 1862, and pensioned. Doyle, Baenaed, Private, Co. C, 38th Indiana Volunteers, aged 25 years. Kenesaw Mountain, June 6th, 1864. Fracture of cranium. Loss of left eye. Savannah, New York, and Madison hospitals. Discharged June 11th, 1865, and pensioned. Deake, Ethan A., Private, Co. G, 7th Illinois Volunteers. Farmington, Mississippi, May 9th, 1862. Loss of left eye. Field hospit.al. Discharged November 3d, 1862. Daniel, J. li.„ Private, Co. B, 1st Virginia Regiment. Gunshot wound of face. Missile entered ball of left eye and emerged at angle of inferior maxilla. Spottsylvania, May 16th, 1864. Admitted to hospital at Farmville, Virginia. Furloughed, for sixty days, September 2d, 1864. Dimmaey, Joseph, Private, Co. E, 29th Connecticut Volunteers, aged 47 years. Gunshot wound of left side of face; destruction of left eye. Bermuda Hundred, September 8th, 1864. Discharged October 28th, 1865, and pensioned. Daniel, Moses, Private, Co. B, 8th Tennessee Regiment. Gunshot fracture of superior maxilla, right eye destroyed. Franklin, Tennessee, November 30th, 1864. Transferred to Provost Marshal January 31st, 1865. Doyle, John, Corporal, Co. C, 6tli Wisconsin Volunteers, aged 25 years. Gunshot wound of face. Conoidal ball entered beneath the left eye and emerged at back of left ear, destroying the left eye. Hatcher’s Run, Virginia, February 6th, 1885. Discharged August 22d, 1865. Duval, Alvay S., Private, Co. C, 111th Illinois Volunteers, aged 28 years. Gunshot wound of face, missile cutting outer canthus of right eye, fracturing orbital process of malar bone, and destroying the sight of the eye. Atlanta, Georgia, J uly 22d, 1864. Discharged March 8th, 1865. He is not a pensioner. Sect. II.] GUNSHOT WOUNDS OF THE EYE. 335 Dunx, Jajies W., Private, Co. A, 8tli Illinois Volunteeis. Gunshot wound of face. Missile entered left zygomatic process, passed slightly upward and backward and emerged on opposite side just above the zygoma. The optic nerve of the right eye was earned away and the eye forced forward. Vicksburg, Mississippi, June 22d, 1863. Insensible for three days. Fragments of bone thrown off. Gangrene. Mustered out July' 30th, 1864, and pensioned. Delamater, Joseph W., Private, Co. H, 124th New York Volunteers. Gunshot wound of face ; left eye lost; also wound of right hand. Chancellorsville, Virginia, May 3d, 1863. Died May 25th, 1863. Ecke, Henry, Private, Co. H, 6th Wisconsin Volunteers. Gunshot fracture of nasal bone and extirpation of left eye. Antietam, Maryland, September 17th, 1862. Transferred to Invalid Corp.s, November 15th, 1863 ; afterward discharged and pensioned. Eaton, Oliver P., Private, Co. G, 86th Illinois Volunteers. Jonesboro’, September 1st, 1864. Fracture of frontal and destruction of right eye by conoidal ball. Field, Chattanooga, and Nashville hospitals. Discharged ISIay 30th, 1865, and pensioned. Egan, Barney, Private, Co. F, Olst New York Volunteers. Port Hudson, June 14th, 1863. Loss of sight of left eye. Port Hudson and Baton Kouge hospitals. Eight eye sympathetically affected. Discharged November 21st, 1863, and pensioned. Egan, John, Private, Co. M, 13th New York Cavalry, aged 20 years. Piedmont, October 19th, 1864. Left eye torn out by ball ; also wound of left arm. Field hospital. Eight eye and nervous system generally affected. Discharged August 2d, 1865, and pensioned. Ellis, IF., Private, Co. F, 19th Virginia Eegiment. Fracture of frontal and loss of left eye. Confederate hospital, Eich- mond. Deserted October 29th, 1862. Everly, Frederick, Private, Co. F, 15th Missouri Eegiment, aged 20 years. Springhill, December 26th, 1862. Fracture of left malar, temporal, and palate bones, and injury of right eye and left ear. Nashville, Jeffei’sonville, and Evans- ville hospitals. Hearing of left ear lost. Discharged iMay 11th, 1865. Elder, Willi,AM, Private, Co. F, 03d Pennsylvania, aged 21 years. Wilderness, May 5th, 1864. Fracture of frontal and temporal bones, eye destroyed; also wound of right foot. Field and Washington hospitals. Amputation of foot. Died May 30th, 1864. Ende, Henry, Private, Co. C, 83d Pennsylvania Volunteers, aged 17 years. Cold Harbor, Virginia, June 1st, 1864. Fracture of left temporal bone, also wound of right eye. Field, Alexandria, and York hospitals. Died August 24th, 1864, from inflammation of brain. Free, James, Private, Co. K, 55th New York Volunteei's, aged 19 years. Fair Oaks, May 31st, 1862. Loss of right eye. Washington hospital. Died July 8th, 1862, of typhoid fever. Fitzgerald, Charles II., Sergeant, Co. C, 138th Pennsylvania Volunteers, aged 32 years. Winchester, September 19th, 1864. Loss of right eye. Eegimental, Sandy Hook, and Philadelphia hospitals. Left eye sympathetically affected. Discharged February 14th, 1865, and pensioned. Fitzrjerald, James, Private, Co. G, 5th Louisiana Eegiment, aged 18 years. Eappahannock Station, November 7th, 1863. Fracture of ft’ontal and orbital bones, loss of vision of left eye. Taken prisoner, and treated at Washington hospital. Transferred to Old Capitol Prison for exchange April 14th, 1864. Finch, Egbert, Sergeant, Co. B, 1st Michigan Sharpshooters, aged 22 years. North Anna Eiver, May 25th, 1864. Fracture of frontal, temporal, and malar bones, right side, by conoidal ball. Field and Washington hospitals, Vision of right eye destroyed. Discharged October 3, 1864, and pensioned. Fowler, J. O., Private, Co. F, 1st Wisconsin Volunteers. Perryville, October 8th, 1862. Loss of left eye. Perryville and Louisville hospitals. Vision of right eye impaired. Discharged December 20th, 1862, and pensioned. Funk, David, Corporal, Co. I, 5th Pennsylvania Eeserves. Fredericksburg, December 13, 1862. Fracture of cranium, and sight of left eye destroyed. Field, Washington, and Philadelphia hospitals. Amaurosis of right eye. Discharged March 3d, 1863, and pensioned. Goi’F, John, Private, Co. E, 11th Ohio Cavalry. Fracture of frontal bone, and destruction of right eye. Eegimental hospital. Left eye sympathetically affected. Discharged December 4th, 1865. Pension claim pending. Greenleaf, James M., Private, Co. C, 145th Pennsylvania Volunteers. Fredericksburg, December 13th, 1862. Frac- ture of frontal bone, and loss of right eye; also fracture of lower jaw. Field and Washington hospitals. Discharged April 6th, 1863, and pensioned. Grier, Sylvanus, Private, Co. K, 124th New York Volunteers. Chancellorsville, May 3d, 1863. Loss of right eye. Field hospital. Discharged November 1st, 1864. Left eye subsequently became very defective. Pensioned. Gunst, Peter, Private, Co. I, 2d Michigan Volunteers, aged 21 years. Petersburg, June 17th, 1864. Loss of light eye. Also fracture of ring finger of right hand, necessitating amputation. Field and Washington hospitals. Discharged July 28th, 1865, and pensioned. Godwin, H. TV., Sergeant, Co. C, 5th North Carolina Eegiment, aged 26 years. Gunshot wound of face. Ball entered the right eye, completely destroying it, and remained imbedded in the bony structure of the face. Cedar Creek, Virginia, October 19th, 1864. Sight of left eye impaired. Grover, John, Private, Co. C, 11th Connecticut Volunteers, aged 23 years. Gunshot wound of left side of face; loss of left eye. Drury's Bluff, Virginia, Jlay 16th, 1864. Eeturned to duty December 15th, 1864. He is not a pensioner. Gunther, John, Private, Co. A, 16th Michigan Volunteers, aged 27 years. Eappahannock Station, Virginia, November 7th, 1883. Shell wound, destroying globe of left eye. Washington hospital. Discharged M.arch 20th, 1864, and pensioned. 336 WOUNDS AND INJURIES OF THE FACE, [Chap. II. Gailey, Andrew, Private, Co. G, lOItli Ohio Volunteers, aged 44 years. Gunshot fracture of left malar hone; eye destroyed. Franklin, Tennessee, November SOth, 1864. Discharged May 18th, 1865. Genung, Calvin, Private, Co. A, 109th New York Volunteers, aged 44 years. Gunshot fracture of malar bone tind destruction of right eye. Weldon Railroad, Virginia, August 19th, 1864. Spiculat of bone removed at various times. Discharged January 25th, 1865. A. M. M., Photographic Series, Vol. II, page 1. He is a pensioner. Gier, John, 1st Missouri Cavalry, aged 40 years. Gunshot fracture of jaw ; destruction of right eye. Fair Oaks, Virginia, October 13th, 1804. Transferred to Veteran Reserve Corps, and discharged J uly 28th, 1865. He is not a pensioner. Gailey, IVilliam R., Sergeant, Co. C, 40th Indiana Volunteers. Chattanooga, November 25th, 1863. Fracture of frontal and left malar bones, with loss of left eye. Field hospital. Died December 23d,T863. Groves, J. P., Captain, Co. B, 1st Louisiana Regiment. Monocacy, July 9th, 1864. Fracture of temporal and orbital bones, with loss of left eye. Frederick hospital. Died July 18th, 1864. Haight, W. J. T., Private, Co. K, 151st New York Volunteers, aged 20 years. Monocacy Junction, July 9th, 1864. Fracture of right temporal and loss of right eye by conoidal ball. Frederick, Baltimore, and Philadelphia hospitals. Discharged April 18th, 1865, and pensioned. Harman, H. V., Captain, Co. G, 2d North Carolina Regiment. Fracture of left temporal and orbital bones; sight of left eye destroyed. Baltimore hospitals. Sent to post prison at Fort McHenry, June 9th, 1865. Harper, Robert, Private, Co. M, 102d Pennsylvania Volunteers, aged 22 years. Wilderness, May 5th, 1864. Fracture of right frontal with depression, and destruction of right eye, by conoidal ball. Washington and Pittsburgh hospitals. Discharged November 14th, 1864, and pensioned. Haven, Francis M., Private, Co. H, 17th Kentucky Volunteers, aged 20 years. Shiloh, April 6th, 1862. Fracture of frontal bone, with loss of right eye. Discharged August 29th, 1862. Hemmer, Peter, Corporal, Co. I, 30th Indiana Volunteers. Murfreesboro’, December 31st, 1862. Loss of left eye. Field, Nashville, and Louisville hospitals. Discharged September 24th, 1864, and pensioned. Henry, Edwin, Private, Co. A, 2d United States Artillery, aged 32 years. City Point, July 23d, 1864. Fracture of frontal bone and loss of right eye. Field and New York hospitals. Discharged January 12th, 1865, and pensioned. Hill, Isaac, Private, Co. C, 24th Virginia Regiment, Gettysburg, July 1st, 1863. Fracture of frontal and destruction of left eye. Taken prisoner. Gettysburg and Baltimore hospitals. Paroled September 25th, 1863. Houts, George W., Lieutenant, 7th Missouri Cavalry, aged 37 years. Jefferson City, October 6th, 1864. Fracture of orbital and temporal bones and loss of left eye by conoidal ball. Jeflerson City hospital. Returned to duty November 3d^ 1864 ; discharged April 20th, 1865, and pensioned. Havens, Morton, Lieutenant, Co. H, 7th New York Heavy Artillery, aged 26 years. Gunshot fracture of left superior maxilla, with loss of left eye. Petersburg, Virginia, June 16th, 1864. Transferred to Veteran Reserve Corps November 11th, 1864 ; discharged and pensioned. Huffman, J. D., Private, Co. E, 7th Pennsylvania Volunteers. Gunshot wound through nose and loss of one eye. Admitted to Georgetown College Hospital September 6th, 1862. Discharged December 3d, 1862. He is not a pensioner. Huntsinger, Henry J., Private, Co. A, 48th Indiana Volunteers. Gunshot wound of right eye and fracture of lower jaw. Admitted to Hospital No. 2, Paducah, Kentucky, November 1st, 1862. Discharged December 26th, 1862, with loss of right eye, and pensioned. In February, 1869, he was losing the sight of his left eye. Holm, John H., Private, Co. D, 80th Hlinois Volunteers. Gunshot fracture of nasal bones and injury of right eye; sight destroyed. Day’s Gap, Alabama, April 30th, 1863. Returned to duty September 7th, 1863; discharged and pensioned. Holley, John, Private, Co. G, 58th Massachusetts Volunteers, aged 17 years. Gunshot fracture of malar bone and loss of left eye. Cold Harbor, Virginia, June 3d, 1864. Returned to duty January 23d, 1865; discharged and pensioned. Hinds, Peter, Private, Co. E, 17th New York Volunteers, aged 45 years. Gunshot fracture of right malar bone and destruction of right orbit. Jonesboro’, Georgia, September 1, 1864. Discharged May 22d, 1865. Not a pensioner. Hoover, Thomas A., Corporal, Co. D, 107th Pennsyh'ania Volunteers, aged 16 years. Gunshot wound of face. Missile entered just below the inner angle of left eye, crushed through the superior maxilla back of nasal bones, passed transversely backward through right eye, destroyed it, and emerged three-fourths of an inch in front of upper lobe of right ear. Gettysburg, Pennsylvania, July 1st, 1863. Intense tumefaction of right side of face supervened. Lower eyelid everted. August 7th, wounds had healed. Transferred to Invalid Corps, December 31st, 1863. Not a pensioner. Hewitt, Edward G., Private, Co. H, 15th Massachusetts Volunteers. Gunshot wound of face. Missile entered under left eye, fracturing the bone badly. Fair Oaks, Virginia, May 31st, 1862. Missile not recovered. Left eye nearly blind. A sinus opened near left ear, discharging pieces of bone and pus. Discharged February 18th, 1863, and pensioned. Haskins, John C., Private, Co. B, 24th Texas Cavalry, aged 24 years. Fragment of shell struck left side of face, carrying away the entire malar bone and destroying left eye. Arkansas Post, January 11th, 1863. Recovered and sent to prison May 4th, 1863. Helper, John, Private, Co. L, 14th Pennsylvania Cavalry, aged 23 years. Conoidal ball entered near the external angle of the left orbit, passed through the ball, inward and downwai’d through the posterior nares, and lodged opposite the angle of the right inferior maxilla, in the sterno-cleido-mastoid muscle. Greenbrier, Virginia, August 26th, 1863. Missile removed. Transferred to Veteran Reserve Corps. Not a pensioner. Sect. II.] GUNSHOT WOUNDS OF THE EYE. 337 Hill, George, Sergeant, Co. G, 64tli Oliio Volunteers. Chattanooga, November 25th, 1863. Musket hall entered left eye, destroying it, and emerged on right side of face, near angle of jaw, fracturing the superior maxilla. Vision of right eye impaired. Cumberland Hospital. Discharged August 17th, 1864, and pensioned. Ilsley, Natii.,\js'IEL, Private, Co. I, 35th Massachusetts, aged 27 years. Cold Harbor, June 5th, 1864. Fracture of frontal bone and loss of left eye. Field, Washington, and Portsmouth hospitals. Secondary haemorrhage. Returned to duty October 13th, 1864; discharged June 9th, 1865, and pensioned. Jesse, T. S., Private, Co. A, 29th Virginia Regiment. Fracture of spine of scapula and orbital process of frontal bone right side ; right eye involved. Richmond hospital; no result recorded. Joiixsox, John, Private, Co. H, 49th Ohio Volunteers, aged 19 years. Buzzard Roost, May 9th, 1864. Fracture of left temporal and destruction of left eye. Field, Louisville, Camp Dennison, and Columbus hospitals. Right eye impaired; vertigo. Discharged June 2d, 1865, and pensioned. Jones, Edwin R., Private, Co. E, 7th Illinois Volunteers, aged 23 years. Allatoona, October 5th, 1864. Fracture of outer edge of right supra-orbital ridge, with loss of eye, by conoidal ball. Field, Nashville, Jeffersonville, and Springfield hospitals. Removal of fragments. Returned to duty February 28th, 1865; discharged ^lay 13th, 1865, and pensioned. Joyce, Patrick, Private, Co. A, 115th New York Volunteers, aged 25 years. Petersburg, June 29th, 1864. Fiaclure of frontal bone at left orbital ridge, with loss of left eye. Field, Point Lookout, and Washington hospitals. Transferred to Veteran Reserve Corps February 25th, 1865; discharged June 28th, 1865, and pensioned. Jacobs, John JV., Private, Co. F, 54th North Carolina Regiment, aged 30 years. Gunshot wound of face. Mi.ssile destroyed the right eye and passed out at the angle of the superior maxilla, fracturing the bone. Fisher’s Hill, Virginia, September 22d, 1864. Examined, to be retired, March 14th, 1865. Jones, John, Private, Co. B, 3d South Carolina Battery. Missile entered the superior maxillary of left side about one and a half inches in front of the ear and passed out just back of the outer angle of right eye, destroying the globe of tlx; l ight and the sight of the left eye. South Mountain, Maryland, September 14th, 1862. Loss of sensation in left cheek ; difficulty in opening mouth. The pupil of left eye contracted and not sensible to light. Returned to duty December 13th, 1862. Kenyon, Paris, Private, Co. B, 105th Illinois Volunteers. Atlanta, August, 1864. Fracture of left supra-orbital ridge and nasal bones; eye destroyed. Field hospital. Died August 16th, 1864. Kenyon, Elias W., Private, Co. A, 154th New York Volunteers, aged 34 years. Pine Knob, June 15th, 1864. Frac- ture of frontal bone and destruction of right eye. Field, Nashville, and Louisville hospitals. Vision of left eye impaired. Discharged December 28th, 1864, and pensioned. Kerr, Michael, Private, Co. D, 7th Rhode Island Volunteers. Fredericksburg, December 13th, 1862. Fracture of frontal bone, with loss of left eye. Field and Washington hospitals. Vision of right eye very imperfect. Discharged from service February 5th, 1863, and pensioned. Kiles, Jacob B., Private, Co. F, 110th Ohio Volunteers, aged 20 years. Cold Harbor, June 3d, 1864. Loss of left eye. Field, Washington, York, and Philadelphia hospitals. Discharged June 14th, 1865, and jHnisioned. Kimberlin, John, Private, Co. E, 9th Illinois Volunteers, aged 20 years. Fort Donelson, February 15th, 1862. Loss of left eye. Cincinnati hospital. Discharged August 14tli, 1862, and pensioned. Kuhn, Oliver, Private, Co. L, 198th Pennsylvania Volunteers, aged 19 years. Hatcher’s Run, March 29th, 1865. Fracture of portions of malar and sphenoid bones and destruction of right eye. Field, Washington, and Philadelphia hospitals. Discharged June 28th, 1865, and pensioned. Killing sworth, P. D., Private, Co. I, 51st Georgia Regiment. Gunshot woinid of face. Missile destroyed the right eye and fractured upper and lower jaw. Chancellorsville, Virginia, May 3d, 1863. Retired from service April, 1865. Can open the mouth but little and is unable to masticate. Kenyon, David, Private, Co. C, 3d Maryland Volunteers. Gunshot wound of left side of face. Destruction of left eye and fracture of left superior maxillary bone. Antietam, Maryland, September 17th, 1862. Discharged April 16th, 1863, and pensioned. ^ Kemp, Charles, Private, Co. B, 11th Connecticut Volunteers. Gunshot fracture of superior malar bone; left eye destroyed. Antietam, Maryland, September 17th, 1862. Discharged February 6th, 1863. Sense of smell destroyed. He is a pensioner. Lemon, Moses W., Lieutenant, Co. I, 14th New York Heavy Artillery, aged 34 years. Washington, March Ist, 1865. Fracture of temporal bone with loss of left eye. Washington hospital. Discharged May 6th, 186-5, and pensioned. Lindsay, Joseph, Private, Co. C, 72d Pennsylvania Volunteers, aged 27 years. Malvern Hill, July Ist, 1862. Frac- ture of temporal and loss of right eye. Baltimore hospital. Discharged November 16th, 1862, and pensioned. Lynde, James H., Lieutenant, Co. I, 14th New York Heavy Artillery. Fort Steadman, February 25th, 1865. Fracture of frontal bone, with loss of right eye. Field and City Point hospitals. Discharged August 26th, 1865, and pensioned. Lewi.S, H. B., Private, Co. A, 121st New York Volunteers, aged 18 years. Gunshot wound of face, with loss of right eye. Ball entered middle of right eyebrow and exit through mouth. Chancellorsville, Virginia, May 3d, 1863. Returned to’ duty September 9th, 1863. Discharged and pensioned. Lomas, WTlliam, Pi-ivate, Co. H, 2d Pennsylvania Heavy Artillery, aged 30 j'ears. Gunshot wound of face, left eye destroyed. Petersburg, Virginia, Juno 18th, 1864. Removal of several spiciila; of bone. The lower eyelid is drawn to a V shape and attached to the mtilar bone. Discharged May 16th, 1865. Not a pensioner. 43 338 WOUNDS AND INJURIES OF THE FACE, [Chat. II. Lynch, Patimck, Private, Co. F, Gtli Vermont Volunteers, aged 35 years. Gunshot wound of face. Musket ball entered left cheek in front of ear and emerged at the side of the nose. Charlestown, Virginia, August 21st, 1864. Left eye completely gone ; riglit eye very weak. Discharged May 5th, 1865, and pensioned. Leech, Albeut G., Private, Co. H, 2d Vermont Volunteers, aged 25 years. Gunshot wound of face. Conoidal ball entered at right supra-orbital arch, destroyed eye and passed into mouth. Cedar Creek, Virginia, October 19th, 1864. Paralysis of right side of face; mastication and speech difficult. Discharged May 12th, 1865, and pensioned. Lackey, Wiliaam J., Private, Co. II, 102d Pennsylvania Volunteers, aged 35 years. Gunshot wound of face. Conoidal ball outered just anterior to inner angle of right eye, fractured the nasal bones, passed directly through left eye and emerged Just j>osterior to its outer angle. Cedar Creek, Virginia, October 19th, 1864. November 22d, the wound had nearly healed. Discharged February 27th, 1835, and pensioned. Larimer, Isaac, Sergeant, Co. K, 35th Illinois Volunteers. Missile entered the right malar bone, close under orbit, fractured and destroyed a ])ortion of orbital process, passed through palate bone into the mouth, grazed ramus of left inferior maxilla, and emerged through left side of neck. Discharged Sej)tember 27th, 1864. Loss of vision of left eye. He is a pensioner. Lippincott, Deni.s, Private, Co. D, 5th United States Infantry. Gunshot fracture of superior maxillary and nasal bones; loss of right eye. Valverde, New Mexico, February 21st, 1862. Discharged June 25th, 1862, and pensioned. McCoy, John P., Private, Co. H, 77th Illinois Volunteers, aged 22 years. May 16th, 1863. Loss of right eye. Mem- ])his hospital. June 15th, secondary hmmorrhage from temporal artery. Returned to duty July 20th, 1863. Partial blindness of left eye. Discharged March 7th, 1835, and pensioned. McEwinG, Henry, Private, Co. D, 2d Michigan Volunteers. Petersburg, December 11th, 1864. Loss of right eye. Field, City Point, Baltimore, and Philadelphia hospitals. Ball extracted. Left eye sympathetically affected. Discharged June 23d, 1865, and pensioned. Marion, Thomas, Private, Co. I, 108th Ohio Volunteers, aged 25 years. Kenesaw Mountain, .June20th, 1864. Fracture of frontal bone, and loss of left eye. Field, Nashville, Louisville, and Gamp Dennison hospitals. Discharged May 31st, 1865, and pensioned. Masters, Aquii.la, Sergeant, Co. E, 14th Ohio Volunteers, aged 23 years. Chickamauga, September 20th, 1863. Fracture of right temporal bone, with loss of vision of right eye. Field, Chattanooga, Nashville, and Columbus hospitals. Discharged July 11th, 1834, and pensioned. Mieler, John W., Private, Co. K, 55th Pennsylvania Volunteers. Pocotaligo, South Carolina, October 22d, 1862. Fracture of frontal and temjioral bones, ivith loss of right eye, Hilton Head hospital. Hearing of right ear impaired. Dis- charged December 14th, 1832, and pensioned. Miller, William II., Private, Co. B, 3d New York Artillery, aged 23 years. Honey Hill, November 30th, 1864, Injury of frontal and temporal bones, and destruction of right eye. Hilton Head hospital. Dischai-ged May 9th, 1865, and pensioned. Morgan, James E., Corporal, Co. K, 15th Iowa Volunteers, aged 22 years. Cedar Bluff, September 2d, 1864. Fracture of frontal and nasal bones, with injury to left eye. Field and Keokuk hospitals. Nearly complete loss of vision of left eye, and impaired hearing of left ear. Discharged July 26th, 1865, and pensioned. MooitE, William, Private, Co. F, 119th Pennsylvania Volunteers, aged 36 ye.ars. Rappahannock Station, Virginia, November 7th, 1863. Loss of left eye. Washington and Philadelphia hospitals. Incipient and progressive amaurosis of right eye. Discharged Mai'ch 22d, 1835, and pensioned. Murphy, Hugh, Private, Co. D, 17th Wisconsin Volunteers, aged 30 years. Bentonville, North Carolina, March 21st, 1865. Fracture of angle of left orbit, and destruction of left eye. Field, New Berne, New York, and Madison hospitals, Discharged May 23d, 1835, and pensioned. McMiller, John, Private, Co. A, 82d Iowa Volunteers, aged 28 years. Gunshot wound of face. Missile struck the right maxillary bone, and siilitting, passed through the right eye and right frontal sinus. Pleasant Hill, Louisiana, April 9th, 1864. The two pieces of ball were extracted. Dischargod*February 14th, 1865. Pension of eight dollars per month granted February 14th, 1865. Softening of the brain supervened. Constant headache and other cerebral symptoms. Muckel, William, Piiv.ate, Co. H, 3d New York Volunteers, aged 21 years. Gunshot wound of left side of face, destruction of eye. Petersburg, Virginia, July 30th, 1864. Transferred to Veteran Reserve Corps, May 4th, 1865. Disch.arged and pensioned. My'ers, Michael, Sergeant, Co. F, 72d Illinois Volunteers, aged 42 years. Gunshot fracture of nasal bone, with loss of left eye. Franklin, Tennessee, November 30th, 1864. Discharged May 0th, 1865, and pensioned. Marcy, Edward, Private, Co. D, 91st Ohio Volunteers, aged 41 years. Gunshot wound of face. Conoidal ball entered left malar bone and emei'ged through right malar bone, destroying sight of left eye. Winchester, Virginia, September 19th, 1864. Transferred to Vetenan Reserve Corps, February 10th, 1865. He is not a pensioner. Minkler, George W., Private, Co. C, 128tli New York Volunteers, aged 21 years. Gunshot fracture of superior maxilla and nasal bones. Cedar Creek, Virginia, October 19th, 1864. Blepharo-conjunctivitis of left eye. Loss of use of right eye. Discharged May 20th, 1865, and pensioned. Miner, Henry, Private, Co. C, 10th Vermont Volunteers, aged 36 years. Gunshot fracture of nasal bones; missile ))assed through ball of left eye. Winchester, Virginia, September 19th, 1884. Ball extracted fiom cavity of eye. Left eye completely gone, right eye very weak. Discharged Ajiril 6th, 1865, and pensioned. Sect. II.] . GUNSHOT WOUNDS OF THE EYE. 339 Menghani, W. T., Private, Co. K, 21st North Carolina Eegiraent, aged 21 years. Gunshot wound of orbit ; missile carried away the eye and emerged from the nose. Fort Fisher, North Carolina, January 13th, 1865. Released June 28th, 1865. Millaed, Isidore, Private, Co. H, 10th Missouri Cavalry, aged 29 years. Missile entered anterior to meatus auditorius externus, passed forward and downward and emerged at rigid orifice of anterior nares, destroying sight of right eye. Selma, Alabama, April 2d, 1865. Discharged May 31st, 1865. Not a pensioner. IMoerison, Ht?Gii, Sergeant, Co. C, 100th Pennsylvania Volunteers. Gunshot wound of face. Missile entered behind left mastoid process and emerged through left eye, carrying away the eye. South Mountain, Maryland, September 14th, 1862. Discharged November 27th, 1862. Left side of face paralyzed. Great deformity. Cannot shut the right eye. He is a pensioner. SIaetix, Thomas B., Priv.ate, Co. E, 96th Illinois Volunteers. Gunshot wound of face. Conoidal musket ball entered right eye, completely destroyed the eyeball and fractured the orbital and nasal bones. Chickamauga, Georgia, September 20th, 1863. Several haemorrhages occurred, which were controlled by pressure at first, and afterward by ligation of right common carotid immediately above the omo-hyoid muscle. Died December 19th, 1863. McGrady, Jacob, Private, Co. F', 37th North Carolina Regiment. Gettysburg, July, 1863. Gunshot wound of eye. Gettysburg hospital. Died July 14th, 1863. Noblet, Peter, Sergeant, Co. I, 28th Wisconsin Volunteers, aged 26 years. Gunshot fracture of nasal bones; conoidal ball passed transversely and destroyed the right eye. Spanish Fort, Alabama, March 30th, 1835. Mustered out September 23d, 1885, and pensioned. Nichols, Norman J., Private, Co. G, 2d Vermont Volunteers. Gunshot wound of face. Conoidal musket ball entered at outer angle of right eye, fractured malar bone and emerged under the inferior maxilla. Wilderness, Virginia, May 5th, 1864. Sight of right eye destroyed. Discharged May 27th, 1865, and pensioned. Nash, J. P., Private, Co. A, 21st Virginia Regiment, Gettysburg, July 2d, 1833. Loss of right eye. Farmville hospital. Retired from service June 3d, 1864. Ne.vle, Fielding, Adjutant, 98th New York Volunteers, aged 36 years. Petersburg, June 25th, 1864. Loss of right eye. Point of Rocks, Fort Monroe, and Annapolis hospitals. Discharged November 26th, 1864. O’Donnell, James, Sergeant, Co. A, 7th Illinois Volunteers. Gunshot fracture of right malar bone, eye destroyed. Allatoona, Georgia, October 5th, 1884. Returned to duty February 9th, 1865. Discharged and pensioned. OiVKBALL, Ned, Private, Co. D, 2d Indian Home Guards, aged 23 years. Conoidal ball entered at the right eye and emerged posterior to the left side of mouth. Fort Gibson, Cherokee Nation, April 7th, 1884. Lo.ss of right eye. Returned to duty May 31st, 1835. Not a pensioner. Packard, Albert H., Captain, Co. G, 31st Maine Volunteers. Wilderness, May 6th, 1834. Penetrating fractuD! of cranium by musket ball, which lodged in brain substance ; eye destroyed. Field and Washington hospitals. Died May 16th,1864. Peeler, John, Private, Co. K, 134th New York Volunteers. Gunshot wound of face. Missile struck the margin of tlie auditory canal of right side, passed forward and inward through the socket of the right eye, and lodged just within the internal angle of the orbit. Gettysburg, Pennsylvania, July 1, 1863. Ball removed August 3d. Eye was completely destroyed. Died August 23d, 1863. Perciiteld, W. j.. Private, Co. H, 82d Indiana Volunteers, aged 39 years. Gunshot wound through apex of nose and destruction of right eye. Atlanta, Georgia, August, 1834. Disclnii'ged June 14th, 1865, and pensioned. Purdy, Elum, Private, Co. H, 84th Illinois Volunteers, aged 22 years. Gunshot fracture of zygoma; right eye destroyed. Buzzard Roost, May 9th, 1834. Returned to duty January 24th, 1865; discharged and pensioned. Pott, Henry, Private, Co. D, 75th Illinois Volunteers, aged 20 years. Gunshot wound of face. Conoidal musket ball carried away nasal bones, destroyed left eye, and fractured zygomatic process of malar bone. Lovejoy Station, September 3d, 1864. Discharged January 25th, 1865, and pensioned. Powers, J. T., Private, Co. D, 20th North Carolina Regiment. Gunshot wound of face and loss of right eye. Discharged November 30th, 1862. Peck, George G., Corporal, Co. D, 7th Massachusetts Volunteers, aged 32 years. Fredericksburg, May 3d, 186.3. Fracture of frontal bone and loss of sight of left eye. Field and Washington hospitals. Discharged December 19th, 1863, and pensioned. Pradt, John C., Priv’ate, Co. A, 3d Wisconsin Cavalry. Baxter Springs, Kansas, October 0th, 1863. Fracture of cra- nium and entire destruction of left eye. Post hospital. Fort Scott. Returned to duty December 11th, 1863; discharged August 17th, 1837, and pensioned. Pearce, James M., Private, Co. M, 11th Pennsylvania Reserves. Bull Run, Virginia, August 29th, 1862. Gunshot wound ; ball entered right orbit, destroyed the right eye, passed through the face, fracturing the nasal and maxillary bones, and emerged from the opposite side, in the cervical region of the neck. Washington hospital. Discharged October 30th, 1862, and pensioned. Raab, George, Private, Co. B, 9th Pennsylvania Reserves. Antietam, September 17th, 1862. Fracture of frontal bone, with loss of right eye. Discharged November 15th, 1862, and pensioned. Rader, David, Captain, Co. A, 23th Indiana Volunteers. Morganzia, September 29th, 1863. Fracture of right temporal bone and destruction of right eye. New Orleans hospital. Returned to duty November 6th, 1863; discharged March 11th, 1864, and pensioned. Ransoji, Sutton, Piivate, Co. E, 1st United St.ates Colored Cavahy, agcM 20 years. Bermuda Hundred, June 17lh, 1864. Fracture of temjioral and destruction of left eye. Point Lookout hospital. Returned to duty November 14th, 1864. 340 WOUNDS AND INJURIES OF THE FACE, [Chap. II. Redding, Williaji A., Private, Co. A, fitli New Hampshire Volunteers. Bull Run, August 30th, 1862. Loss of left eye and ileraugement ot intellect. Washington Iiospital. Vision of right eye impaired. Discharged June 27th, 1863, and pen- sioned. Reese, ClIADEES, Captain, Co. D, 20th Indiana Volunteers. Gettysburg, July 2d, 1863. Loss of right eye. Gettys- burg and Washington hospitals. Discharged October 22d, 1863. Regeing, Ciiristopiieu, Private, Co. G, 3d Michigan Volunteers, aged 35 years. Wilderness, May 6th, 1864. Fracture of temjioral bone, with loss of right eye. Field, Washington, and Detroit liospitals. Headache, vertigo, and mental aberration. Discharged August 29th, 1864, and jtensioned. Reynolds, Daniel M., Corporal, Co. F, 49th Pennsylvania Volunteers, aged 21 years. Spottsjdvania, May 10th, 1804. Fracture of frontal and nasal boties and destruction of right eye. Field, Washington, and New York hospitals. Imperfect vis- ion of left eye. Returned to duty July 28th, 1884; discharged December 22d, 1864, and pensioned. Riley, Michael, Co. K, 35th Massachusetts Volunteers. Antietam, September 17th, 1862. Loss of left eye. Frede- rick hospitals. Discharged December, 1862, and pensioned. Roe, Joseph, Corporal, Co. C, 91st New York Volunteers, aged 28 years. South Side Railroad, April 2d, 1865. Frac- ture of nasal and malar bones and loss of left eye. P'ield and Washington hospitals. Discharged August 3d, 186.5, and pen- sioned. RoGEiiSON, Andi:ew B., Lieutenant, Co. A, 20th Illinois Volunteers, aged 27 years. Chattanooga, July 10th, 1864. Fracture of temporal and nasal bones and destruction of right eye. Chattanooga, and Nashville hospitals. Senses of taste tind smell nearly destroyed. Discharged May 15th, 1865, and jiensioned. Iioss, J. A., Private, Co. C, 36th North Carolina Regiment, aged 23 years. Destruction of left eye. Point Lookout hos* pital. Transferred to provost marshal April 8th, 1885. RuTTEn, E., Private, Co. E, 2d Maryland Volunteers, aged 19 years. August 19th, 1804. Wound ofleft temple, involv- ing eye and nose. Richmond hospital. Returned to duty October 19th, 1804. Rogehs, Alvin, Private, Co. C, 77th Illinois Volunteers. Gunshot fracture of facial hones. Conoidal ball struck just over the left eyebrow, passed downward, destroying the eye, and lodged in the superior maxilla. Vicksburg, Mississippi, May 22d, 1863. Vision of right eye also impaired. Discharged July 10th, 1833, and pensioned. Reynolds, D. M., Lieutenant, Co. E, 184th Pennsylvania Volunteers, aged 21 years. Conoidal ball entered at inner angle of right eye, and passed through eye and cheek ; another ball lodged near head of tibia. Deep Bottom, Virginia, August 14th, 1864. Discharged December 24, 1804. Not a pensioner. Rothenbeegei!, IL, Sergeant, Co. D, 48th Pennsylvania Volunteers, aged 21 years. Gunshot wound of face. Conoidal ball entered at the inner canthus of left eye, passed downiward and backward, and lodged outside of angle of inferior maxilla. Petersburg, April 2d, 1805. Missile removed. Left eye was entirely destroyed. Returned to duty July 0th, 1865. Discharged and pensioned. Ross, John M., Private, Co. H, 8th Pennsylvania Volunteers. Gunshot wound of face. Missile entered the left eye, passed obli(|uely through sujierior maxilla, and emerged oj)i)osite and m^arthe mastoid process. Fredericksburg, December 13th, 1802. Discharged January 24th, 1863. Left eye destroyed. I’ensioned. Richaedson, John, Private, Co. B, 14th Illinois Volunteers. Gunshot wound of face. Missile entered through inferior eyelid, near the external angle of left eye, passed between the eyeball and external wall of orbit, and lodged. Shiloh, Tennessee, April 0th, 1862. Ball removed six weeks after reception of injury. Discharged September 29th, 1862. Loss of vision of left eye, and difficulty of hearing. He is a pensioner. SiiAEFFEE, Petee, Private, Co. M, 12th Ohio Cavalry, aged 18 years. Accidentally, near Lexington, June 11th, 1864. Perforating fracture of cranium ; loss of left eye. Lexington hospital. Died June 12th, 1864. Sanders, Henry C., Private, Co. B, 2Cth Maine Volunteers, aged 20 j'ears. Spottsylvania, Virginia, May 8th, 1864. Fracture of cranium, and loss of left eye, by conoidal ball, which lodged. Field, Washington, and New York hospitals. Dis- charged May 26th, 1805, and ])ensioned. Schuler, Joseeii A., Sergeant, Co. C, 3d Michigan. Mine Run, Virginia, November 27th, 1803. Fracture of angular process of temporal hone, and destruction of left eye. Regimental and Fairfax hospitals. Transferred to Veteran Reserve Corps, March 25th, 1864. Incipient cataract of right eye. Discharged June 17th,. 1804, and pensioned. SiiAitP, Matthew, Private, Co. I, 82d Pennsylvania Volunteers, aged 36 years. Sailors Creek, Virginia, April Gth, 1865. Fracture of frontal bone, with loss ofleft eye. Field, City Point, and Washington hospitals. Discharged June 14th, 1865, and jiensioned. Shaver, William IL, Private, Co. H, 3d New York Artillery. Petersbuig, September 13th, 1864. Fracture of frontal bone, and destruction of right eye. Fort Monroe, and New York hospitals. Discharged June 27th, 1835. Sheley, George A., Lieutenant, Co. M, 1st Michigan Light Artillery. Cumberland Gap, Vhginia, June 18th, 1804. Fracture of frontal bone, with loss of right eye; also fracture of right scapula, and flesh wounds of right arm and right hip. Detroit hospital. Discharged October 15th, 1864. Shively, David L., Private, Co. E, 114th Pennsylvama Volunteers. Gettysburg, July 2d, 1863. Loss of right eye; also fracture of right clavicle. Gettysburg, Baltimore, and Philadelphia hospitals. Discharged May 14th, 1864, and pensioned. Complete paralysis of right up])er extremity. Sect. II.] GUNSHOT WOUNDS OF THE EYE. 341 Sickles, Willi.\m, Private, Co. G, 73d Ohio Volunteers, aged 20 years. Eesaca, May lOth, ISOl. Fractureof craninni, ■with loss of left eye. Field, Chattanooga, Nashville, Louisville, Camp Dennison, and Columbus hospitals. Discharged June 13th, 1865, and pensioned. Slack, Aldex S., Corporal, Co. I, 3d Vermont Volunteers, aged 26 years. Winchester, September 19th, 1864. Fracture of frontal bone, with loss of right eye; also fracture of right leg. Field, Baltimore, Brattleboro’, and Montpelier hospitals. Discharged June 12th, 1865, and pensioned. Slocum, Warren, Private, Co. G, 111th New York Volunteers, aged 21 years. Wilderness, May 5th, 1864. Fracture of frontal, orbital, and maxillary bones, and destruction of left eye. Field, Washington, Chester, and New York hospitals. Discharged September 5th, 1864, and pensioned. Has constant pain in head, with frequent attacks of vertigo. Statler, Eudolpii, Private, Co. I, 33d Missouri Volunteers, aged 20 years. Pleasant Hill, April 9th, 1864. Fracture of orbital bones, with loss of left eye. Field and Memphis hospitals. Eeturned to duty November 17th, 1864. Stewart, IF. N., Private, Co. G, 43d North Carolina Eegiment. Sitottsylvania, May 10th, 1864. Loss of left eye. Eetired March 6th, 1865. Had constant pain, headache, and vertigo, and loss of sense of taste and smell. Had also oecasional attacks of epilepsy. Stukes, Patrick, Private, Co. F, 28th Massachusetts Volunteers, aged 28 years. Spottsylvania, May 12th, 1H()4. Fracture of frontal bone and loss of left eye. Had previously received wounds of abdomen and foot. Field, Washington, Eeadville, and Worcester hosj)itals. Discharged July 21st, 1865, and pensioiu^d. Stratton, Isaac, Sergeant, Co. F, 7th Ohio Volunteers. Gettysburg, July 3d, 1863. Fracture of left supra-orbital arch, with loss of left eye. Seminary and York hospitals. October 1st, removal of fi'agments of ball. Eeturned to duty October 21st, 1863. Killed near Dallas, Georgia, May 25th, 1864. Smith, Elias, Private, 2d Iowa B.attery. Gunshot wound of left orbit ; loss of sight. Vicksburg, Mississip[)i, May 22d, 1863. Eeturned to duty September 28th, 1863. Not a pensioner. Shafer, Anthony, Corporal, Co. K, 23d Pennsylvania Volunteers, aged 22 years. Conoidal ball passed through nose and emerged at the outer corner of the right orbit, entirely destroying the right eye. Co'd Harbor, Virginia, June 1st, 1864. Discharged October 14th, 1864. Not a pensioner. S.MITH, Andrew J., Private, Co. C, 7th Wisconsin Volunteers. Conoidal ball struck right eye, p.assed downward, tmd lodged in left side of neck. Gettysburg, Pennsylvania, July 1st, 1863. Ball extracted by an incisiem in left side of neck. Eight eye destroyed. Transferred to Veteran Eeserve Corps September 9th, 1863. Not a pensioner. Shannon, Ja.mes J., Corporal, Co. B, 83d Ohio Volunteers. Gunshot wound of left eye. Arkansas Post, January 1 1th, 1863. Died January 19th, 1863. Seal, Zachariah, Private, Co. B, 15th New Jersey Volunteers. Gunshot wound through eye and fracture of jaw. Discharged March 9th, 1863, and pensioned. Slocum, John A., Private, Co. H, ISOih Pennsylvania Volunteers, aged 20 years. Gunshot fracture of nasal bone. Conoidal ball struck the outer angle of left eye, cutting the eyelid, and causing the loss of sight. Also fracture of cuboid bone by shell. Gettysburg, Pennsylvania, July 1st, 1863. Eeturned to duty December 12th, 1884. Discharged and j)ensioned. Stiner, Joseph, Private, Co. H, 203d Pennsylvaida Volunteers, aged 21 years. Gunshot injury of j;iw ; right eye destroyed. Fort Fisher, North Carolina, Jtvnuary 15th, 1865. Discharged April 23d, 1865, and pensioned. SiiEPLER, Peter, Sergeant, Co. B, 6th Pennsylvania Eeserve Corps. Gunshot fracture of right orbit; eye torn out; under lid carried away. Spottsylvania, Virginia, May 10th, 1864. Discharged July 17th, 1865. Ai>pearance re|)ul.sive. Not a pensioner. Semich, Juliu.S, Private, Co. A, 26th Wisconsin Volunteer.s, aged 25 years. Missile entered outer angle of right mbit, (hestroyed right eye, passed through both superior maxillary bones and lodged at st'cond upper mohir, left side. Atlanta, Georgia, July 20th, 1864. TransfeiTed to Veteran Eeserve Corps, Decend)Pr 20tli, 1864. Discluirged and pensioned. Senior, John, Private, Co. B, 35th Massachusetts Volunteers. Antietam, Seiitember 17th, 181)2. Gunshot fracture of superciliary ridge and frontal bone. Baltimore ho.spital. Discharged November 2()th, 1862, and pensioned. Vertigo and impaired vision of the right eye. Staclcley, D. II., Private, Co. H, 59th Alabama Eegiment, aged 25 years. Gunshot wound of face. Conoidal hall entered over outer angle of orbit, passed downward and backward, and emerged at angle of inferior maxilla of opposite side. Eight eye destroyed. Spottsylvania, May 16th, 1864. Furloughed June 7th, 1864, nearly recovered. Syates, Sylvester, Private, Co. A, 18th Georgia Eegiment, aged 19 years. Missile, conoidal b:ill, entered right eye, and pas.sed out of left. Burksville, Virginia, April 6lh, 1865. Eelea.sed May 7th, 186.5, on taking the oath of allegiance. Sutton, Sylvester, Private, Co. A, 14th Michigan Volunteers, aged 21 years. Atlanta, Georgia, August 7th, 1864. Fracture of temporal, frontal, and malar bones, with loss of vision of Tight eye. Field, Chattanooga, Jell'ersonville, and Detroit hospitals. Discharged March 2d, 1865 ; died September 7th, 1866. Sweet, Linford, Private, Co. A, 49th New York Volunteers, aged 24 years. Antietam, September 17th, 1862. Destruction of left eye, nose, malar and turbinated bones. Antietam and Smoketown hospitals. Great disfiguration. Dis- charged December 6th, 1862, and pensioned. Tiiompkins, Thomas, Corporal, Co. B, 14th Wisconsin Volunteers. Gunshot fracture of facial bones. Missile entered left side of nose, one-half inch below inner canthus, and emerged one-half inch in front of right ear. Eight eye destroyed. Corinth, Mississippi, October 3, 1862, Discharged March 31st, 1863. Not a i)ensioner. 342 WOUNDS AND TNJITPJES OF THE FACE, [Chap. II. Tate, Samitel G., Private, Co. I, 4tli United States Cavalry. Fracture of frontal bone, with loss of right eye. Louis- ville hospital. Eeturned to duty March 11th, 1803. Discharged April 22d, 1863, and pensioned. UzELMEYER, JOHN, Private, Co. I, 1st Delaware Volunteers, aged 20 years. Wilderness, May 5th, 1804. Fracture of external table of frontal bone, with loss of left eye. Field, Washington, and Chester hospitals. Transferred to the Veteran Deserve Corps, May Cth, 1865. Discharged September 15th, 1865, and pensioned. An unknown soldier of the 3d Alabama, admitted to Washington hospital, April 24th, 1865, from City Point. Conoidal ball lodged in orbit of left eye. Died April 30th, 1865. VoSBUiiG, Stephen II., Sergeant, Co. F, 63d New York Volunteers, aged 24 years. Gunshot wound of face. Conoidal ball traversed base of nose, destroying right eye. Cold Harbor, Virginia, June 1st, 1864. Transferred to Veteran Deserve Corps April 5th, 1865. Discharged and pensioned. Wclton, G. IF., Private, Co. F, 12th Virginia Degimeiit. Loss of ej’^e. Dichmond hospital. Furloughed September 7th, 1864. White, Charles F., Private, Co. F, 114th New York Volunteers, aged 21 years. Cedar Creek, Virginia, October 19th, 1864. Fracture of skull, and destruction, also, of right eye. Great dishguration. Baltimore and Philadelphia hospitals. Transferred to the Veteran Deserve Corps. Discharged June 15th, 1865, and pensioned. Whitlock, John, Private, Co. A, 1st New Jersey Volunteers, aged 21 years. Spottsylvania, Virginia, May 11th, 1864. Fiacture of orbital and temporal bones, with loss of right eye. Field, Washington, and Philadelphia hospitals. Discharged May 19th, 1865, and pensioned. Will, George F., Private, Co. I, 77th New York Volunteers, aged 22 years. Wilderness, May 6th, 1864. Fracture of orbital and temporal bones, with loss of left eye. Washington, Philadelphia, New York, and Albany hospitals. Sympathetic affection of l ight eye. Discharged December 13th, 1864, and pensioned. Williams, Alexander N., Private, Co. A, 85th Indiana Volunteers. Atlanta, Georgia. Fracture of temporal, with loss of left eye. Field, Chattanooga, and Nashville hospitals. Transferred to Veteran Deserve Corps December 21st, 1864. WiTHEY', Lemon B., Private, Co. C, 136th New York, aged 25 years. Gettysburg, July 2d, 1863. Fracture of mahar bone, and loss of left eye. Gettysburg, York, and Alexandria hospitals. Spiculffi extracted. Discharged May 25th, 1865, and pensioned. Williams, Asbury^, Private, Co. D, 23d Indiana Volunteers. Vicksburg, May 19tb, 1863. Fracture of cranium at base of brain, with loss of left eye. Field hospital. Died June 8th, 1863. "Wait, Eli, Corporal, Co. B, 5th Minnesota Volunteers. Gunshot wound of face. Missile entered orbit of right eye, destioying the sight, crossed the face under the nose, and lodged in antrum of left side. Vicksburg, Mississippi, 1863. Trans- ferred to Veteran Desei've Corps, and returned to duty December 7th, 1863. Not a pensioner. Works, Wi!IGHT, Private, Co. B, COth New York Volunteers, aged 20 years. Gettysburg, Pennsylvania, July 3d, 1863. Gunshot wound of facial bones, with loss of eye. Demoval of spiculae of bone and lead at various times. Deturned to duty June 28th, 1864. Discharged and pensioned. Walker, A., Private, Co. Iv, Palmetto Sharpshooters, South Carolina. Gunshot fracture of facial bones and loss of left eye. Petersburg, Virginia, October 7th, 1864. Furloughed for sixty days, November 4th, 1864. Walton, Mathew, Corporal, Co. K, 61st Ohio Volunteers, aged 24 years. Gunshot fracture of facial bones, with loss of right eye. Peach Tree Creek, Geoigia, July 20th, 1864. Left eye impaired. Discharged March 20th, 1865, and pensioned. Williams, Orm.yndo M., Private, Co. E, 5th Vermont Volunteers, aged 21 years. Gunshot fracture of bones of face; left eye destroyed. W^ilderness, Virginia, May 6th, 1864. Ball remained in wound for three or four years, when it was finally removed from the throat by the patient during a choking 6t. Discharged November 16th, 1864, and pensioned. Wilford, James M., Sergeant, Co. D, 4th Tennessee Dcgiment. Gunshot fracture of nasal bone ; right eye destroyed. Franklin, Tennessee, November 30th, 1864. Sent to provost marshal January 7th, 1835. Weeks, George M., Sergeant, Co. C, 56th Massachusetts Volunteers, aged 21 years. Gunshot wound of face. Conoidal ball entered at junction of right malar and frontal bones, traversed orbit and nasal cavities, and emerged at inner angle of left orbit. Petersburg, Virginia, September 30th, 1864. Loss of right eye. Deturned to duty January 23d, 1865 ; afterward discharged and pensioned. Watson, Thomas J., Private, Co. H, 115th Illinois Volunteers, aged 19 years. Gunshot wound of face. Buckshot entered half an inch to outside of right eye, passed inward and downward, and emerged from cheek, near left angle of mouth, knocking out several teeth; also fracture of right ulna in lower third. Docky Face, IMay 9th, 1864. Discharged October 7tb,- 1864. Vision of right eye destroyed; that of left slightly impaired, as also mastication and speech. Flexion of fingers imperfect. Ho is a pensioner. Of the foregoing series of two hundred and fifty-four cases of gunshot injury of one eye, twenty were fatal, the mortality being due to grave complications involving the brain or branches of large vascular trunks. In forty-one of these cases, vision in the uninjured eye became affected sympathetically, and in four instances was ultimately lost. The Sect. II.] GUNSHOT WOUNDS OF THE EYE. 343 aggregate of gunsliot injuries of tlie eye reported, from which the preceding abstracts were selected, is set forth in the following table : Table XI. Table of Eleven Hundred and Ninety Cases of Gunsliot Wounds of the Eye. EXTENT OF INJURY. Cases. Died. Duty. Discharged. Unknown. Destroying sight of both eyes 63 17 44 2 Destroving sight of right eye T. . . 393 12 87 286 8 Destroying sight of left eye 387 24 95 253 10 Destroying sight ; side not given 4.5 11 9 17 8 Injuring sight of riglit ej^e - 25 9 13 3 20 8 8 4 Injuring sight j side not stated G 1 2 3 106 71 24 11 Undetermined cases j left eye 116 83 20 13 Undetermined cases; side not stated 29 16 7 6 Aggregate 1, 190 64 379 679 68 In ninety-one cases where the eye was destroyed, the sight of the remaining eye was impaired or sympathetically affected. The table does not include cases of burns of the face reported, not unfrequently caused l^y magazine explosions or the premature ignition of cartridges, when it often happened that grains of powder were driven beneath the conjunctiva and, unless promptly removed, became encysted and indelibly disfigured the sclerotica while yet more serious consequences, as corneal oj^acity, traumatic cataract, or general ophthalmitis, were not uncommon. Systematic writers on ophthalmology class with gunshot wounds of the eye, cases of injuries of that organ from bits of gravel or other hard bodies thrown up by bursting shells or by the impact of large projectiles on masonry. Such instances were, probably, infrequent in the late war, as no specific details of any examples are found recorded.*]* The intrusion of fragmeilts of percussion caps into the eye was also a rare accident, but nineteen instances being mentioned in the large series of reports classified as gunshot injuries of the eye. In three of the cases, the side on which the injury was inflicted was not reported ; in ten, the right, and in six, the left eye was involved. Five of the patients were returned to duty, with little impairment of vision, one was placed on modified duty in the Veteran Reserve Corps, eight were discharged, and five remain unaccounted for. It can be gleaned from the scanty details given, that the men who were returned to duty had non-penetrating injuries of the cornea or of the exposed part of the globe ; that the' eye was lost when the foreign body had entered the posterior chamber, and that the only recoveries after penetration of the ■ * Captain Worden received an injury of this sort in the famous action witli the Merriinac, and it used to be said in the army that he should blusli with a pardonable pride whenever he looked in the min'or. t Lord Nelson lost an eye from this cau.se at the siege of Calvi, as related in a letter to his wife, August 18tli, ITM. TyUKKi.l. (Vol. I, p. 367), Ammon (Zeitschrifl, 15. Ill, ,S. 103), Dr. I. I. IlAYES (3d Am. cd. of Lavvuencic On the Eye, p. 182), and Ma'ITIIEW (Surf/. Uisl. of liril. Army in Ih^ Crimea, p. 310), record similar eases. 344 WOUNDS AND INJURIES OF THE FACE [Chap. II. {interior chamber were those in which the copper fragment was immediately extracted.* The injuries of the eye from pistol and musket balls and from fragments of large projectiles were very varied in their nature. (Jommouly destructive of vision, they were seldom dangerous to life, unless associated with fractures involving the cranial cavity. There were twenty-five examples, of which some particulars have been given, of recovery after the evulsion of both eye-balls by shot traversing the orbits. There were two instances [Zimmerman and Ferdon, p. 327, ante) of recovery after the passage of musket balls behind the orbits, from temple to temple, the total blindness that ensued indicating the probable division of the optic nerves anteriorly to their decussation. Specimen 1,108, of the Museum (see Fig. 103, p. 205) illustrates how bullets may readily pursue this course without involving the anterior cerebral lobes. The percentage of recovery, where a single eye was torn from its socket by a bullet, was large, and the secondary lesions of the brain or of the opposite eye were less frequent, after this rude mode of extirpation, than in cases in which buckshot or small pistol balls lodged within the globe. No case is recorded explicitly of the lodgment of a ball in the orbit, without injury to the globe, unless the case of Kichardson (p. 340, ante) may have been of that nature. Hennen met with an instance of this sort during the retreat of Sir John Moore’s army to Corunna, and has described it in his fifty-second observation. (Op. cit, p. 346.) The flattened bullet was extracted by dressing forceps, and there was but slight irritation of the eye, “although he underwent a very distressing march that night.” The eyelids rarely escaped injury in gunshot wounds- of the contents of the orbit; but in a few instances the globe was emptied by a musket ball, with slight lesion of the lids. Eversion and inversion of the lids, ancyblepharon and symblepharon, and various adhesions of the remnants of the lids to the margins of the orbit followed in many of this class of cases. A tew instances are illustrated by photograjJis in the Museum ;-j- others will be described with the cases of blepharoplasty, in the next section of the chapter. Missiles seldom penetrated or destroyed the eyeball without injuring the bones forming the orbit. In the foregoing pages of this section, many instances have been cited of extensive fractures of the facial bones, associated with gunshot wounds of the eye, and in the preceding chapter may be found examples of fractures involving the frontal sinuses (p. 164, Pigs. 74 and 75) and upper osseous boundary of the orbit. Unless the lesions of bone extended to the cranial cavity the results were seldom fatal. In many instances of these distressing species of injuries, recovery took place, or the fatal result was long deferred unless complicated with cerebral mischief ; the fractures of the external walls of the frontal and maxillary sinuses were not dangerous, though followed by necrosis, with interminable exfoliations and frequent abscesses. There was no carefully reported case of amaurosis induced by the division of the supraorbital nerve by balls, and nothing in the reports to sanction the assertion of MacKenzie [Am. ed., 1855, p. 416) that the “wind of a ball has been known to produce amaurosis.” The “wind of balls” has long been wafted out of the domain of military surgery. * On percussion caps lodged in the eyeball, consult CiiOMrTON's account of seven cases treated by Barton, cf Manchester {London Med. Gazette, Vol. XXI, p. 171) ; Am. Jour, of Med. Sciences, fur a case of successful removal cf a fragment from the iris by Dr. N. B. Smith; Dr. J. Hays {loc. cit., p. 182); SlTfiVF.NART {Ann. d'Oe., T. I, p. 439); CUNIER {ihid., p. 440); Lawson {Injuries of the Eye, p. 289) gives six cases. StoEBER (in W. \V. Cooper's Wounds and Injuries of the Eye, London, 18G9, p. 391). t See Photographs of Surg. Cases and Specimen.^, A. &I. M., Vol. I, p. 32; Ihid. Vol. IF, p. 2; Ihid. Vcl. II, p. 18; Ihid. Vol. VI, p. 0; Ihid. Vol. VII, i>. 8; Card Photographs of Surgical Cases, A. M. M., Vol. I, p. 4; Ihid. Vol. I, p. 4; Ihid. Vol. I, p. 10; Ibid. Vol. I, p.3; Ihid. Vol. I. p.3; Ihid, Vol. I. p. 3; Ihid. Vol. I, p. 4. Sect. II.] GUNSHOT WOUNDS OF THE EYE. 345 Gunsliot contusions of tlio globe of the eye were not unfrcqucntly followed by traumatic cataract. I have searched in vain in the records for such instances of recovery from this lesion as Larrey recorded [Clin. Chir. T. 1®, p. 403), of recovery of perfect vision, or even of useful vision, after unquestionable instances of wounds of the crystalline.'^ A general survey of the accounts of gunshot injuries of the eye, reported during the war, instructs us that whenever foreign bodies are lodged in the globe, they should be extracted at all hazards. If it is impracticable to find them, the globe should be extirpated in order to preserve the other eye. When general opthalmitis has followed a gunshot injury, a free horizontal incision, evacuating the contents of the eyeball, should not be long delayed. Absolute rest, and strict diet, and every precaution that may conduce to the preservation of the remaining eye, should, with sedulous solicitude, be enjoined by the surgeon. In the cases complicated by fractures of the orbital region, it was plainly shown that it was unwise to remove fragments of bone primarily, unless they were so detached as to serve as foreign bodies. In the dressing of gunshot wounds of the eyelids, often exhibiting much loss of tissue, favorable results were obtained by the careful readjustment of the mutilated parts, with coaptation by the twisted suture, the contused edges of the wound being pared in some instances. But this method of reunion, so very serviceable in wounds about the face, was not very generally employed. In cases attended by destruction of the puncta or of the lachrymal canals, some of them having been under the observation of pension examiners or army surgeons for six or seven years, little or no diminution in the overflow of tears took place, a result conflicting with the assertions of oculists who have obliterated the puncta with alleged success in cases of epiphora or stillicidium. Artificial eyes were furnished to a few of the mutilated soldiers; but, in most instances, the destruction of tissue in gunshot injuries involving the globe of the eye, made it inadvisable to attempt the insertion of a glass eye.f Gunshot Fractures of the Facial Bones. — Among the abstracts of wounds of the orbital region, many examples of injuries of the adjacent bones have been cited. The following one hundred and thirty-eight abstracts relate mainly to cases involving the upper and lower maxillae chiefly; but strict classification has not been attained in this series of complicated cases: Case. — Private James Berks, Co. K, 138th Pennsylvania Volunteers, aged 60 years, received, at the battle of Locust Grove, November 27th, 1863, a gunshot wound of the face, right side. The missile entered over the right angle of the jaw, and emerged beneath the symphysis, comminuting the jaw between both wounds. Several spiculac of bone were removed on the * Consult Laruey, Scarpa, IIky, IIennen, Vicq-u’Azyr on this disputed iioint. t Obsen'ations on {gunshot wounds of the eye may be found in Beer, Lehre der Augenkrankheiten, Wien, 1792, B. 1, S. 95 ; in IlEXNEN, Prin- ciples of Military Surgery^ 3d ed., Loudon, J829, p. 344 ; GUTIIRIR, Commentaries, etc., p. 523 ; W. W. COOPER, On Wouyjds and Injuries of the Eye, Loudon, 1809, p. 59; BELL, System of Operative Surgery, London, 1814, 2d ed., p. 452; THOMSON, Observations in the. British Military Hospitals in Belgium, Edinboro’, 1816, p. 05 ; MacleOD {op. cit.), p. 223 ; DixoN, in Holmes's System of Surgery, Vol. Ill, p. 89, 2d ed. ; Leooukst {op. cit.), p. 305 ; Annales d' Oculistique, T. Ill, p. 73, Bruxelles, 1840; WALKER, Oculists' Vade-mecum, London, 1843, p. 323; McUae, Medical lieport of the Campaign in the Punjauh, p. 48 ; Demours, Traite des Maladies des Yeux, Baris, 1818, PI. 52, fig. 1 ; Penin, Ann. d' Oc., T. XX, p. 105 ; ISCHKNSCIINIED, ibid., T. XXX, p. 107 ; Careon DU ViLLARDS, Gazette Med. de Paris, T. VI, c. 1 ; Playne, Opthalmic Hospital Reports, London, Vol. I. p. 210; Meni^RK, V Uotel-Dieu de Paris, enjuillctlBMO, Paris, 1830; MACKENZIE, A Practical Treatise on the Diseases of the Eye, Am. cd., 1855, p. 412; Stellwao and SOELHERG WELLS, in their recent treatises, add nothing to our information on the subject ; StOEBER, Ann. d' Oc., T. Ill, p. 70 ; Crompton, Lorahm Medical Gazette, Vol. XXI, p. 175 ; Castelnau, Archives General de Medicine ; LAWSON, Injuries of the Eye, Orbit, and Eyelid, London. 1807, p. 282 ; Gama, Traite des plaits de tete ei de Vencephalite, 2d cd., I^aris, 1835, p. 340 ; liAWRENCE, On the Diseases of the Eye, Am. ed., Phila., 1854, p. 182 ; DEVal, Chirurgie Oculaire, Paris, 1844, p. 500; Besmarrks, Traite des Maladies dcs "Yeux, I^aris, 1854, 20 ed. T. I. p. 152; WAi/rON, Operative Opthalmic Surgery, London, 1853, p. 95; Matthew, Surg. Hist, of the War in the Crimea, Vol. II, p. 309; Fardkau, Jour. Gen. de Med. et de Chir., T. 24, Paris, 1809, p. 287 ; Denonvilliers ET OOSSELIN, Compendium {op. cit.), T. HI, p. 413, Paris, 1801 ; Platner, Institutiones Chirurgie, Lipsia?, 1758, p. 322 ; BaUDENS, Cliniques de Plaies d' Armens a Feu, p. 107 ; Lohmeyeu, Die Schusswunden, Zweite Ausgabc, 1809, 8. 99 ; BECK, Die Schusswunden, 8. 139; OCHWADT, Kriegschirurchische Erfahrungen, 8. 354; UOSAS, Handbuch der thcorctischen und pructischen Augenheilkunde, Wien, 1830, B. I, 8. 421 ; DiETKUICII, Archives G4n4rales de Medicine, October, 1820, i>. 295; IlILL, Cases in Surgery, Case V ; GarENOEOI’, Traite des Operations de Chirurgie, T. 3®, p. 155. 44 346 WOUNDS AND INJUKIKS OF THE FACE [Chap. II. field. He was, on December 4tb, admitted to 2d division hospital, Alexandria. On admission, the right side of the jaw had fallen in consideiahly, and the patient was weak and anaemic. Opiates, stimulants, and tonics were administered, and chicken broth, beef tea, and farina ordered. Secondary hmmorrhage from one of the external carotid arteries occurred December 10th, amounting to ten ounces of blood, which was controlled by the application of peisulj)hate of iron. The patient stated that he had recurrent haemorihages. The horizontal ramus of the lower jaw is gone, and he can eat Huid food only. He was discharged the service March 7th, 1864, and pensioned on March 15th. Examining Surgeon H. L. Hodge reports that he has great difficulty in swallowing and very imperfect speech. His mind is weakened ; disability total, probably permanent. The case is recorded by Acting Assistant Surgeon J. G. McKee. Case. — Private William H. Batchelder, Co. I, 16th Maine Volunteers, aged 22 years, was wounded at the battle of Gettysburg, July 1st, 1863, by a conoidal ball, which caused a compound comminuted fracture of the right lateral half of the inferior maxilla, and fractured a portion of the superior maxilla. The ball entered the right side of the face slightly above and to the outside of the right wing of the nose, passing downward and backward, shattering the body of the right superior maxilla and the first and second molars, with the alveolar process of the inferior maxilla, grazing the side of the tongue in its passage. He was sent to the 2d division hospital. First Corps. The ball was removed at the lower side of the mouth. Secondary hatmorrhage from the dental or facial artery occurred J uly 8th, amounting' to about twenty ounces of blood, which was arrested by the application of styptics, .and pressure. On July Iflth, he w.as transferred to York Hospital, Pennsylvania. The patient was put under chloroform, and seven teeth, consisting of five upper and two lower, were removed, besides many jiieces of the superior maxilla. Cold water dressings were applied to the wound. He was restless, and much pained, and had bad appetite. There was considerable discharge of pus in the mouth, the granul.ations filling the gaps in the jaws. On August 21st, the wound of entrance had closed, with some depression of the cic.atrix. He could open the mouth one-half of an inch, but was unable to close it with force; spoke rather plainly, but could not speak when first wounded. He looked rather pale, had good appetite, and slept under morphia. He complained of paroxysms of pain at the root of the neck and shoulders, which yielded to wet cups and morphia ; these paroxysms continued with variiible intensity, and extending to the back of the head, until about the 21st of September, at wbich time it refused to yield to treatment. On the 22d, his face flushed, pulse frequent, irregular, and severe headache. Cups were applied to the back of the neck and cold applic.ations to the head, which gave temporary relief. On the 23d, his condition was unchanged, save slight drowsiness. On the 24th, drowsiness increased, and blisters were applied to the back of the neck. On the 25th, coma, snoring, and death. Necrotomy showed some emaciation, and some congestion of the dura mater. The arachnoid presented an opaque appearance, most marked at the base of the brain; that portion of the brain resting upon the basilar portion of the occipital bone was deeply red, softened, and at one point presented a spot of badly organized lymph, and possibly some pus. The ventricles were distended by several ounces of very clear serum. The case is ref)orted by Surgeon Henry Palmer, U. S. V. Case. — Sergeant George R. Burroughs, Co. G, 12th New Jersey Volunteers, aged 23 years, was wounded at the battle of Cold Harbor, June 3d, 1864, by a conoid.al ball, which fivactured the ramus of the inferior maxilla. The missile entered at the middle of the ramus on the right side, and emerged below the angle on the left side, wounding the lingual and facial arteries. He was, on June 15th, admitted to Harewood Hospital, Washington. Secondary hajraorrhage from the lingual and facial arteries occurred June 17th, amounting to eighteen ounces of blood. Hatmorrhage recurred on the 20th. Free incisions were made in the course of the wound, and coagulated blood and pus cleaned out thoroughly; the haemorrhage thereupon ceased. The consti- tutional treatment throughout was supporting. Died Juno 22d, 1864. Patient seemed to have died fi’om exhaustion superinduced by profuse and protracted suppuration, rather than from the immediate effects of the haemorrhage. The case is reported by Surgeon R. B. Bontecou, U. S. V. Ca.se. — Private James P. Bonham, Co. D, 5th New York Volunteers, aged 22 yeai's, of a nervo-sanguine temperament, and who had always enjoyed perfect health, was wounded at the second battle of Bull Run, Virginia, August 30th, 1862, by a conoidal ball, which entered the left cheek midway on a line drawn from the middle of the margin of upper lip to that of the lobe of the ear, passed along the body of the inferior maxilla, breaking out both upper and lower anterior and posterior molars, causing a compound fracture of the sujierior maxilla, and then striking the palate bone at its posterior edge, glanced off in an oblique direction downward and forward to the right, and lodged in the lingual muscles. He was admitted, on the next day, to the Armory Square Hospital, Washington, in an exhausted condition. Stimulants and nourishing diet were given. The ball could not be found. Spiculae of bone were removed, and cold water dressings applied. On September 6th, the wound was suppurating freely. On September 12th, secondary haemorrhage occurred, probably from the tonsillar or palatine arteries, which was restrained by cold applications. On October 17th, an incision was made one inch in front of the angle of the infeiior maxilla at the lower posterior edge of the gland, and the bullet extracted. It was found to be much flattened and bent, and thickly set with minute spicitlaj of bone. Fomentations were applied to promote suppuration. On October 26th, the wounds in the cheek and fauces were closed, and on the 31st, the parts had assumed nearly their normal condition. He was discharged from service March 31st, 1863. Surgeon D. W. Bliss, U. S. V., reports the case. He is a pensioner, his disability being rated one-third and permanent. Case. — Private Henry Baine, Co. C, 188th Pennsylvania Volunteers, aged 19 years, received at the battle of Cold Harbor, Virginia, June 3d, 1864, a gunshot wound of head and face, conoidal ball entering in front of the meatus auditorius, left side, and emerging at nasal eminence, involving loss of left eye and partial destruction of internal maxillary artery. He was admitted to the Emory Hospital, Washington, on June 10th, 1864. Face much swollen; vision destroyed. Cold water dressings were a|iplied and tonics administered. Patient did well until the evening of June 15th, when secondaiy hajmorrhage took place. He lost from four to six pounds of blood, necessitating operation. On June 16th, at ten A. M., Surgeon N. R. Moseley, U. S. V., ligated the common carotid artery, in superior carotid triangle, just below origin of internal maxillary artery. He died on June 26,th, 1864, from exhaustio:n and debility. The case is reported by tbe operator. SECT. IT.] GUNSHOT FRACTUKES OF TITE FACIAL BONES. 347 Case. — Private Cyrus W. BeanioiulorfVr, Co. A, 84tli Pennsylvania Volunteers, aged 20 years, was wounded at the li.-ittli; of the Wilderness, Virginia, May 6th, 1864, hy a conoidal hall, which entered the left side of the face about half an inch above the angle of the mouth, taking a downward and backward course, and emerged from the left side of the neck, about three inches below the ear, and lodged in the left shoulder. The upper jaw sustained no injury, exce])t the bn-aking off of the first bicuspid. The left side of the under jaw was very much broken, and was resected on the field, ft-om the joint to a point between the two bicuspids. On iMay 12th, 1864, hajmoiThage occurring, the primitive carotid artery was ligated just above the clavicle by Henry McLain, formerly surgeon 2d New York Volunteers. He was admitted to the 1st division hospital, Alexandria, Virginia, May 25th, and on June 20th transferred to Philadelphia, entering Satterlee Hospital on the 22d. His general health was good, and the wounds were almost entirely healed. Cerate dressings were applied. He was discharged from service November 29th, 1864. On October 5th, 1866, Pension Examiner George P. Lineaweaver reports that the muscles of the left side of the neck are so contracted that he cannot turn his head. His disability is rated total. Surgeon I. I. Hayes, U. S. V., reports the case. Case. — Private George Brown, Co. I, 25th Massachusetts Volunteers, aged 41 years, received a gunshot wound of the face at the battle of Goldsboro’, North Carolina, December 14th, 1862. He was on December 20th admitted to Stanley Hospital, New Berne, North Carolina. Secondary luemorrhage occurred January 7th, and recurred on the 9th; the loss of blood amounted to about thirty-two ounces. Cold water dressings were applied to the wound, and stimulants and tonics ordered. Patient died January 18th, 1863. The autopsy revealed an extensive comminution of the malar bone, the zygomatic arch, the antrum, and the petrous portion of the temporal bone ; also laceration of the external carotid artery. The case is reported by Acting Assistant Sui'geon J. B. Uphain. Case. — Private Daniel Cox, Co. F, 15th Indiana Volunteers, aged 25 years', was wounded at the battle of Missionary Ridge, November 25th, 1863, by a musket ball, which entered anterior to left angle of jaw, fracturing lower maxilla, passing under tongue, and out a little below and to the right of the great horn of the hyoid bone ; also injuring the sublingual artery. He was admitted to the field hospital, Chattanooga, Tennessee. Profuse bleeding from sublingual ar tery ; wound rugged ; lost foirr pirrts of blood. November 29th, Sur geon A. McMahon, U. S. V., made arr incisiorr fr orrr point of exit of ball dowrr the neck orr inside of sterno-rnastoid, exposed sheath, with descendens troni rrerve, and ligated right cotnmorr car'otid artery just above onro- hyoid. All bleeding irrstantly ceased. On December 1st, slight hajrrrorrhage ; corrtrolled by persulphate of irorr. December 2d, harmorrhage. December 3d, hjemorrhage; ligation of left external carotid; rto aneesthetic was rrsed. December 6th, weak ; muscffi volitantes. December 9th, frorh this time did well. January 28th, 1864, feels as well as ever; maxilla not united. Left Chattanooga as well as ever, save ft-orn inconvenience of deformed jaw and inability to masticate. Cox was admitted into Hospital No. 19, Nashville, Tennessee, and discharged June 25th, 1864, and pensioned. February 3d, 1866, the wound was still discharging pus. His disability is rated three-fourths arrd permanent. Case. — Brazilla S. Cobb, Co. C, lOth Maine Volurrteers, aged 41 years, was wounded at the battle of Cedar Mourrtain, Virginia, August 9th, 1862, as he was kneeling orr his right krree to discharge his gttn. The missile, a small rifle or revolver ball, struck him in the mouth, driving irr eight teeth, passed to base arrd outer side of right tonsil, and lodged apparently irr the deeper muscles of the neck, in the region of the great vessels. He was admitted irrto the 2d division hospital at Alex- arrdria, Virginia, August 12th, 1862, and was transferred to Satterlee Hospital, Philadelphia. The treatment consisted of Dover’s powders, arrd local applicatiorrs of equal parts of chloroform and tincture of aconite, to the ear, filling the outer ear with loose cotton, bathing the surface of the face arrd head with croton oil. He at first had profuse hcemorrhage from the right ear as well as from the mouth, which recurred several times, with inflammation of the tonsils and fauces, accompanied by tenderness of the right cheek, extendirrg back to the anterior edge of the trapezius. He suffered irrtensely from paitr of the right side of the face and ear, occasioning high fever arrd arterial action, with intense pairr in the head. He was dischar’ged from service Decenrber 30th, 1862, and pensioned, his disability being rated one-half, arrd perhaps not permarrertt. Acting Assistant Sur-geon W. P. Morgarr reports the case. Case. — Private V. F. Clark, Co. G, 98th Vir’gitria Regiment, received, June 23d, 1864, a gunshot wound, which fractured the inferior maxilla. A considerable portion of bone was lost. He was admitted to the Confederate hospital at Far-mville, Virginia. Secondary harmorrhage occurred, and on October 4th he was firrloughed for sixty days. Case. — Private W. B. Copeland, Co. B, 61st Alabama Regiment, aged 34 years, was wounded at the battle of Winchester, Virginia, September- 19th, 1864, by a conoidal ball, which entered just below the angle qf the left eye and lodged in the neck, two inches to the r-ight of the fifth cervical vertebra. He was admitted to tire depot field hosirital at Winchester on the same diiy. Orr October 1st, the ball was removed. On the 7th, the comnton carotid artery was ligated by Surgeorr W. S. Love, C. S. A. Hajmorr-hage recurred, five hour-s after ligation, from the posterior orifice, continuing until the 8th, when he died. Acting Staff Surgeon N. F. Graham reports the case. Case. — B. P. Cox, Dance’s Battery, aged 25 years, received, October 7th, 1864, a gunshot wound. The missile, a conoidal ball, entered the right side of the face, below the middle of the zygoma, and passed out at the posterior edge of the symphysis of the chin. Secotrdary hcemorrhage occurred, which was arrested by compression. October 30th, 1864, good prospect of speedy recovery. Case. — Coiporal Charles A. Chapman, Co. E, 11th New Hampshire Volunteers, aged 18 years, was wounded at the battle of Fredericksburg, December 13th, 1862, by a conoidal ball, which shattered the superior and inferior maxilla, left side. He was, on December 20th, admitted to Carver Hospital, Washington. ''TIk; ball was extracted near the clavicle. On .January 5th, secondary hcemorrhage occurred from the branches of the internal maxillary artery, iimounting to sixteen ounces of blood, which w:is controlled by compression. He was discharged February lltli, 1863. He wiis pensioned, his disability being rated total. 348 WOUNDS AND INJURIES OF THE FACE, [Chap. II. Cask. — Sorgoant D.arclay Cooper, Co. B, 126th Ohio Volunteers, was wounded at the battle of the Wilderness, May 5th, 1864, by a musket ball, whicli entered close to the mastoid ])rocess of the right teinpoial bone, passed through, and lodged under the integuments in the malar bone, beneath the left eye, escaping, in its passage, all the larger vessels, but leaving an opening in the palate. He also received a gunshot wound of the scrotum. He was taken prisoner, and receiving but little attention, the wound of the scrotum became very uidiealthy ; vermin gathered in it, and one testicle became exposed. He states that he was operated upon by a rebel surgeon for the wound of scrotum, after which the parts healed. The wound of the face soon healed, leaving an opening in the palate about the size of a large pea. He was exchanged, and admitted to the post hospital at Camp Chase, Ohio, on January 25th, 1865, and returned to duty on February 21st, 1865. An operation was subsequently performed for the purpose of closing the opening in the palate, but without success; haemorrhage occurred for several days, but finally succumbed under the use of styptics. He was discharged from the service June 25th, 1865. His speech was somewhat defective, and he had difficulty in swallowing. Pension Examiner A. H. Hewetson, M. D., reports the case. Case. — Private Elisha K. DeForest, Co. K, 86th New York Volunteers, received, at Chancellorsville, May 3d, 1863, a gunshot wound. The missile entered the upper lip, passed through the tongue, and emerged from the middle of the sterno- cleido-mastoid muscle, at its external border. He was, on May 4th, admitted to the hospital of the 2d division, Third Corps, and on the 6th transferred to Washington, and on May 8th admitted into the Mount Pleasant Hospital. Half diet was ordered, and the patient enjoined to keep quiet, and his head elevated. On May 12th secondary htemorrhage occurred suddenly, after walking across the ward, and the patient died in a few minutes. May 12th, 1863. The autopsy showed that a part of the common carotid artery had been destroyed by the ball. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. Case. — Private John Downey, Co. E, 73d New York Volunteers, aged 20 years, was wounded at the battle of Gettys- burg, July 1st, 1863, by a conoidal ball, which entered behind and above the lobe of the right ear, passed horizontally across, carrying away the alveolar process of the superior maxilla, and lodged two inches from the tragus of the left ear, one and a half inches from the base of the occipital bone. He was taken to a field hospital, where the operation of exsection was performed. He was admitted into the Seminary Hospital, Gettysburg, July 2d, 1863, and transferred to Turner’s Lane Hospital on the 11th, when a large abscess burst in the posterior part of the cavity of the mouth. The fractured surface of bone was discharging pus freely, also slightly at the external orifice, the wound of the upper lip was healed, pain very slight. The treatment consisted of cold water dressings, nourishing diet, and on July 13th, extraction of ball. On the 20th, a slough formed in the external wound; the discharge was foul. Simple dressings were continued, with injections of Labarraque’s solution into the wound. On the night of August 6th, profuse haemorrhage from the external wound occurred, which was arrested by pressure upon the external carotid, and the free application of persulphate of iron. The amount of blood lost was thirteen ounces. August 11th, he was transferred to Christian Street Hospital in an improving condition. The dressing was removed from the external wound, which presented a clean, healthy surface. The discharge was free. The treatment was continued, with the free use of stimu- lants. By October 1st, the wound and general health of patient were improving. A small splcida of bone was removed. He was discharged from the service November 22d, 1864. The case is reported by Assistant Surgeon C. H. Alden, U. S. A. The ]iatient is not a pensioner. Case. — Private William W. Davis, Co. E, 114th Pennsylvania Volunteers, aged 20 years, was wounded at the battle of Chancellorsville, May 3d, 1863, by a conoidal ball, which fractured the upper maxilla. Tne missile entered the mouth and emerged at the middle of the left cheek, tearing out two inches of outer angle of mouth and destroying seven upper teeth and corresponding alveolar process. He was, on May 8th, admitted to Mount Pleasant Hospital, Washington. Simple dressings were applied to the wound. May 14th, secondary htemorrhage occurred from the facial artery, amounting to about two ounces of blood, which was controlled by pressure. On June 1st, he was transferred to Philadelphia, and admitted into the Satterlee Hospital, whence he was transferred to the 2d battalion. Invalid Corps, September 4th, 1863. He is a pensioner; has very considerable deformity, and neuralgic pains in face in damp weather. Disability, three-fouitbs and permanent. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. Case. — Private Dennis Edwards, Co. A, 11th Massachusetts Volunteers, aged 30 years, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a gunshot missile, wliich ft-actured the inferior maxilla. He was admitted into the hospital of the 1st division. Third Corps, and from thence was admitted into Carver Hospital, at Washington, on May t)th, 1863. There was htemorrhage from the facial artery, which recurred. The treatment consisted of compress and cold applications. He died on May 9th, 1863, of hajmorrhage. Case. — Private James Edgar, Co. G, 81st Pennsylvania Volunteers, aged 23 years, was wounded at the battle of Gettys- burg, July 2d, 1863, liy a conoidal ball, which fractured the inferior maxilla. The missile entered the left side of the neck one-half of an inch below the ear, fracturing the lower maxilla in two places, and crossing beneath the tongue, emerged at the right angle of the mouth. He was, on July 10th, admitted to Broad and Cherry Streets Hospital, Philadelphia. On admission, the patient was exhausted from want of food and rest. Injections of milk punch and beef essence were administered. Several *' spiculffi of bone were removed, and Barton’s bandages applied to the fractured jaw. Secondary haemorrhage from the left lingual artery occurred July lOth, and recurred on the 11th and 12th, amounting to about twenty ounces of blood, which was controlled by pressure. Pulse 100 and feeble ; the wound of entrance gaping and indolent, and tongue swollen. As soon as the patient could take liquor by stomach he improved rapidly. No attempts made to keep the parts in apposition until the close of the sixth week. On September 10th, the union was quite firm, with very little deformity. On September 26th, an abscess, which had formed, discharged pus freely with fragment of ball. A small portion of bone was found necrosed. On October 1st, the patient was convalescent, with no deformity. He was returned to duty January 12th, 1864. The case is reported by Acting Assistant Surgeon William V. Keating. He is a pensioner. On November 10th, 1869, Pension Examiner N. B. Reber reports that the left side of the face is paralyzed; he is unable to close the left eye, rendering it sometimes very weak and sore, which the right eye sympathizes with arrd deranges visiorr. The torrgue is partially paralyzed arrd has growrr fast to the jaw, renderirtg nrasticatiorr irnpossilrle arrd deghrtitiorr difficult. He uses soft food arrd lirprids entirely. Speech imperfect. The woutrd irr the jaw still contirnres to di.scharge interarally. He r-ates his disability as permanent. Sf.ct. II.] GUNSHOT FRACTURES OF THE FACIAL BONES. 349 Private Hiram FHzfjcrahl, Co. E, 3fl. — fiunsliet fnictureof the inferior maxilla. Spec. 1210, Sect. I, A. M. M. 350 WOUNDS AND INJUIIIES OF THE FACE [Chap. II. Case. — Private K. Daj’toii Harvey, Co. K, 167th New York Volunteers, was wounded at the battle of Gettysburg, Penn- sylvania, July 1, 18G3, by a round ball, whieh entered in front of the left ear and passed out of the right cheek. lie was conveyed to the Seminary Hospital the same day, and on July 11th was admitted to the McClellan Hospital, Philadelphia. Secondary limmorrhage occurred on the IGth, which was arrested by means' of persulphate of iron and pressure. He was discharged from service December 2d, 1863. There was total deafness in the lelt ear, and the mental functions were impaired. Surgeon Lewis Taylor, U. S. A., reports the case. The man was pensioned, but died October 31st, 1864, from inflammation of the brain. Case. — Private William M. Hersha, Co. K, 8th Michigan Volunteers, aged 20 3’ears, was wounded at the battle of Cold Harbor, June 3d, 1864, by a conoidal ball, which fractured the inferior maxilla, right side. He was convej’ed to the hospital of the 3d division. Ninth Corps, and transferred to Washington, and on the 9th admitted into Lincoln Hospital. On the 13th, he was transferred to York Hospital, Pennsylvania, where he was admitted on the 14th. Simple dressings were applied to the wound. Sloughing of the arteiy occurred June 28th, and secondary luemorrhage followed, amounting to thirty -five ounces of blood, which all efforts failed to arrest. Patient died June 28th, 1864. The case is reported by Surgeon Henry Palmer, U. S. V. Case. — Sergeant L. D. Inskeep, Co. E, 122d Ohio Volunteers, aged 23 j'ears, was wounded at the battleof Cold Harbor, June 3d, 1864, by a conoidal ball, which entered below the left ej'e, and jrassed out between the shoulders. He was on June 7th admitted to Lincoln Hospital, Washington. Secondary haemorrhage occurred June 13th. Tonics and stimulants were administered. Patient died June 14th, 1864. The case is reported by Assistant Surgeon J. C. McKee, U. S. A. Case. — Private Samuel Jacoby, Co. C, 48th Indiana Volunteers, was wounded at the battle of Corinth, Mississippi, October 3d, 1862, by a gunshot missile, which entered the left cheek, passed through the inferior maxilla, and emerged above the clavicle, wounding the carotid arteiy. He was treated in the regimental hospital until October 13th, 1862, when he was admitted to the Mound City Hospital, Illinois. Secondary hmmorrhage occurred from the common carotid artery October 13th. The patient died October 13th, 1862. The autopsy showed that the cellular tissue about the wound of exit was infiltrated so as to form a firm fibrous ring about the orifice. The mouth was full of clotted blood, and there was an opening in the carotid, just below its bifurcation, one-half of an inch in length. The ball passed through the pharjmx and the root cc tongue. The case is reported by Surgeon E. C. Fraidilin, U. S. V. Case. — Private George W. Lundy, Co. F, 7th Michigan Cavalrv, aged 25 years, received, at the battle of Gettysburg, July 3d, 1863, a pistol-shot wound. The missile entered the superior maxilla below the left eye and through the ala nasi muscle, passed close to the bifurcation of the carotid artery, under the meatus auditorius externus, and emerged a little behind and below the ear. He was on the same day conveyed to the Seminai'y Hospital, Gettysburg. Secondary haemorrhage occurred July 15th, which caused death immediatel}'. On post-mortem examination, the ball was found to have passed in close proximity to the bifurcation of the carotid artery, contusing the coats, which caused inflammation and ulceration, and during a fit of coughing the artery ruptured at bifurcation, causing death. The case is reported by Surgeon Henry Janes, U. S. V. Case. — Private David Loziei-, Co. K, 1st Maine Cavalry, aged 24 j’ears, was wounded at the bfittle of South Side Eailroad, March 31, 1865, by a fragment of shell, which fractured the inferior maxilla. He was on April 4th admitted to Judiciary" Square Hospital, Washington. Secondary haemorrhage from a branch of the left carotid artery occurred April 10th, amounting to ten ounces of blood. The patient died, before assistance could reach him. The case is reported by Surgeon E. Griswold, U. S. V. Case. — Private Alvin G. King, Co. B, 11th New Hampshire Volunteers, aged 32 years, was wounded at the battle before Petersburg, September 30th, 1864, by a conoidal ball, which entered above the arch of the zygoma, fracturing the superior maxilla, and cutting away a portion of the malar bones, all on the left side. He was on the same day conveyed to the hospital of the 2d division. Ninth Corps. On October 2d, he was admitted into the field hospital. Ninth Corps, and transferred to the 2d division hospital, Alexandria, where he was admitted October 12th. Cold water dressings were applied to the wound. Secondary haemorrhage from a branch of the internal maxillary artery occurred October 19th, amounting to forty-eight ounces of blood. Styptics were applied, and stimulants and tonics administered. Haemorrhage recurred every six hours. Patient died October 21st, 1864. The post-mortem examination revealed the ball embedded in the posterior nares. The case is reported by Surgeon Edwin Bentley, U. S. V. Case. — Private D. W. Kilburn, Co. I, 1st Maine Volunteers, aged 22 years, was wounded at the battle of Spottsylvania, Virginia, May 19th, 1864, by a conoidal ball, wliicli entered angle of mouth, making its exit near posterior border of sterno- cleido-mastoideus muscle, wounding facial and external carotid arteries. He was admitted to the Finley Hospital, Washington, on May 28th, 1864. On May 29th chloroform was administered, and the right carotid artery was ligated by Acting Assistant Surgeon J. C. Nelson. Severe haemorrhage ensued after ligation. The patient continued to do well until the evening of June 1st, when he complained of severe pain in region of head and chest; also great dyspneea. He died on June 2d, 1864, from asphyxia. Case. — Private John Lynn, Co. F, 37th Wisconsin Volunteers, aged 23 years, was wounded at the battle of South Side Kailroad, April 2d, 1865, by a conoidal ball, which entered the body of the left malar bone, passed through the buccal cavity, and made its exit through the body of the inferior maxilla, near its right angle, comminuting both bones. He was conveyed by' steamer to Washington, and admitted iuto Harewood Hospital April 5th. The treatment of the patient was rendered somewhat dillicult from the fact that the passage of the ball through the buccal cavity had produced intense pharyngitis and mdema of the adjacent tissues, so that the food, though carefully selected, could only be with difficulty administered ; while the particles of food and salivary secretions could only effectually be removed by syringing through both wounds of entrance and exit. Second- ary hsemorrhage from the internal ma.xillary and facial arteries occurred April 9th, amounting to thirty ounces of blood. The sinking of the patient was so decided as to be beyond the control of any operative measures or medical treatment. The l)atient died April 9th, 1865. The post-mortem examination showed that the facial artery, at the point where it passes over the inferior maxilla, had been laid o|)en. The case is reported by Surgeon Iv. B. Bontecou, U. S. V. Skct. II.] GUNSHOT FRACTURES OF THE FACIAL BONES. 351 Case. — ^Private Charles G. Lincoln, Co. C, 22d Massachusetts Volunteers, received at the battle of Fredericksburg, Virginia, December 13th, 1SG2, a gunshot fracture of tlie superior maxillary. He was conveyed to the hospital of the 1st divis- ion, Fifth Corps, the same day, and on December 17th ^vas admitted to the Eckington Hospital, Washington. Secondary haemorrhage occurred, and the patient died on December 24th. Assistant Surgeon S. A. Storrow, U. S. A., reports the ciise. Case. — Private Adam Mv'ers, Co. C, 130th Pennsylvania Volunteers, aged 23 years, received at the battle of Antietam, September 17th, 1862, a gunshot comminuted fracture of the upper and lower jaws, and laceration of the lingual artery and its branches. He was conveyed to the hospital of the 3d division. Second Corps, and on September 20th, transferred to Harrisburg, Pennsylvania, where he was admitted into tlie Walnut Street Hospital. Stitnulants and tonics were administered, and styjjtics ajtplied to control the hmmorrhage. Pymmia supervened September 24th. The condition of the patient was bad, and no ap])arent etfect was produced by treatment. The j)atient died September 29th, 1832. Ca.se. — Sergeant George B. Merchant, Co. K, 4th Ohio Volunteers, aged 33 years, received at the battle of Spottsylvania, Virginia, May 10, 1834, a gunshot wound of neck, with fracture of inferior maxilla. He was admitted to Douglas Hospital, Washington, on May 13th, 1864. General health good. Secondary haemorrhage occurred, to the amount of eighteen fluid ounces, probably from internal maxilla. On May 15th the right common carotid was ligated by Assistant Surgeon William Thomson, U. S. A. On May 31st, ligature came away. He recovered, and was returned to duty on June 19th, 1884. The case is reported by the operator. The i)atient is a pensioner. Examiner L. M. Whiting I'eports, Se))tember 20th, 1864, that more than half of the ramus of the right side of the lower jaw is gone, and that there is very limited use of the right arm, owing to some injury during the ligation.' Case. — Private J. Morris, Co. I, 50th Georgia Regiment, was wounded at the battle of Cold Harbor, June 1st, 1864, by a conoided ball, which entered at the left angle of the inferior maxilla, and (anerged from the mouth, producing extensive com- minution of the inferior maxilla. He was admitted to the Receiving and Wayside Ilosiiital, at Richmond, Virginia, the same day, where spiculm of bone were removed by incision along the ramus of the jaw. The wound was closed by wire sutures. On June 13th, haemorrhage occurred, which was controlled by the application of persulphate of iron. Food was given him through a tube up to the 14th, and on the 15th he was furloughed for sixty days. No further information. Case. — Private John B. Mcllroy, Co. C, 45th Pennsylvania Volunteers, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal ball, which entered the upper lip, passed through cheek, fracturing the inferior maxilla, and injuring the internal maxillary artery, and made its exit at left ear ; then entered the shoulder, fracturing the acromion jirocess of the scapula. He was admitted to the Fairfax Seminary Hospital, near Alexandria, Virginia, on June 7th, 1864. His constitutional condition was good. Cold water dressings were applied. Hsemorrhage occurred, and on June 18th the common carotid artery, just above omo-hyoid, was ligated by Acting Assistant Surgeon J. 11. York. He died on Juno 19, 1864, in con- sequence of haimorrhage, caused by sloughing of posterior scapular artery, from second ball lodging upon it. The case is reported by Assistant Surgeon II. Allen, U. S. A. C.\SE. — Corporal Henry McDowell, Co. G, 60th New York Volunteers, aged 30 years, was wounded at the battle of Gettysburg, July 2d, 1863, by a piece of shell, carrying away the inferior maxilla. He was on the same day admitted to the field hospital. Twelfth Corps. Secondary haimorrhage from the facial artery occurred July 13th, amounting to about twenty ounces of blood. Patient died July 16, 1863. The case is reported by Surgeon H. Ernest Goodman, U. S. V. Case. — Private John L. Murray, Co. B, 42d New York Volunteers, aged 32 years, was wounded in the engagement at Bristow Station, Virginia, October 14th, 1863, by a conoidal ball, which entered posteriorly to right of spinous process of fifth cervical vertebra, jiassed anteriorly through middle third of inferior maxillary, pioducing compound fracture, and emerged opposite the canine teeth of same side ; the injured parts were badly swollen and inflamed. He was admitted to the third division hospital, Alexandria, Virginia, on October 17th, 1863. On October 25th, chloroform was administered, and the common carotid artery, right side, was ligated, and a partial resection of the lower jaw performed by Surgeon Edwin Bentley, U. S. V. The ligatures came away November 11th, 1863. He was discharged from the service bn February 13th, 1864. The case is reported by the operator. His name does not appear on the pension list. Case. — Private Samuel Meinnis, Co. A, 11th Illinois Volunteers, aged 27 years, was wounded at the battle of Vicksburg, Mississippi, May 22d, 1863, by a musket ball, which entered immediately above and posterior to angle of left jaw, passed through jiharynx and posterior nares, and made its exit at angle (right) of lower jaw, fracturing the bone. He was admitted to the Jackson Hospital, Memphis, Tennessee, on May 27th, 1863; wound suppurating, profuse haemorrhage from external carotid and branches. On May 31st, the common carotid artery was ligated by Surgeon E. M. Powers, 7th Missouri Volunteers. Great general depression of system ; pulse feeble and frequent; considerable febrile excitement and restlessness. Stimulants, nutritious diet, and opiates were administered. No unpleasant symptoms after operation. On June 5th, 1863, jiatient was doing well. He died on June 7th, 1863. The case is reported hy the operator. Case. — Sergeant Francis Maas, Co. E, 6th Kentucky Volunteers, aged 40 years, was wounded at the battle of Resaca, Georgia, May 15th, 1834, by a conoidal musket ball, which entered the mouth, fracturing the inferior maxilla, and emerged through the neck. On May 21st, he was conveyed to the field hospital at Bridgeport, Alabama. Secondary hannorrhage occurred, on the following day, from the inferior maxilla or some of its ramifications, amounting to eighteen ounces, which was arrested by the application of ice. Simple dressings were apjdied, and the wound liealed kindly. He was furloughed July 9th. On August 8th, he was admitted to the Crittenden Hospital, Louisville, Kentucky, and is charged with desertion December Jlst, 1864. He is a pensioner. Assi.stant Surgeon H. T; Legler, U. S. V., reports the case. Case. — Private Patrick McCormick, Co. A, 4tb New York Vidimteer.s, was wounded at the battle of Antietam, Maryland, September 17tb, 1862, by a conoiilal ball, which entered the face, fracturing the npiier jaw, jiassed backward and downward ' In the first issue it w-is erroneously stated that a second ligation was practiced in this case. In a letter of March lUth, 1873, Dr. Whiting makes a handsouic apology fur ascribing the consenucut paralysis to the operation rather than to the injurj’. 352 WOUNDS AND INJURIES OF THE FACE, [Chap. II. through tlio neck, wounding the carotid artery. He was conveyed to the hospital of the Third Corps, and, on September 22d, was admitted to No. 5 Hosj)ital, Frederick, Maryland. September 24th, abscess opened over the thyroid cartilage, and bone extracted. The opening from abscess communicates from above with the mouth, a sinus leading downward toward sternum. He died September 29th, from secondary hatmorrhage from the carotid artery. Autopsy : the missile entered the mouth opposite symphysis of lower jaw, right side, in juring the tongue and soft parts, comminuting the bone up to its ramus, and producing a disloc.'ition outward, and lodged in the inferior triangle of the neck, grazing the common carotid, one inch from its bifurcation. Secondary haemorrhage was from the ulceration of the artery. The jaw was divided at its symphysis. The whole inner surface of sterno-mastoid was dissected. Surgeon H. S. Hewitt, U. S. V., reports the case. Case. — Private A. Mooney, Co. H, 1st New York Artillery, aged 34 years, was wounded May 29th, 1862, by a musket ball. The missile entered the left cheek, fractured the malar bone, and passing backward, emerged parallel to and one inch behind the mastoid process of the left temporal bone. He was, on June 3d, 1862, admitted to the hospital at Annapolis, Maryland. .June 5th, successive secondary hatmorrhages from the infernal maxillary artery. On the 9th, lost from six to eight ounces of blood, which was arrested by the application of ice and injections of the solution of persulphate of iron. On the 16th, he had slight htemorrhage. Patier.t died comatose June 27th, 1862. The case is reported by Surgeon Thomas A. MeParlin, U. S. A. Case. — Private William H. McL , Co. A, 108th New York Volunteers, aged 21 years, was wounded at the battle of Antietam, September 17th, 1862, by a musket ball, which fractured the ramus of the inferior maxilla, left side. The missile entered below the mastoid process of the right temporal bone, passed upward and forward, tr.aversing the parotid gland, and carried away the condyle and a jiart of the ascending ramus of the lower maxilla, and lodged in the zygomatic fossa, severing in its course the temporal and the internal maxillary branches of the carotid artery. He was, on September 26th, admitted to Carver Hospital, Washington. On October 15th, excessive haemorrhage occurred, to the amount of thirty ounces, from the temporal and the branches of the internal maxillary arteries, which was controlled by compression. Haemorrhage recurred on the 21st and 22d. Patient died October 24th, 1862. The pathological specimen is No. 632, Sect. I, A. M. M. The case is reported by Surgeon O. A. Judson, U. S. V. Case. — Corporal Charles Morrow', Co. I, 4th New Jersey Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot fracture of the inferior maxilla, right side. He was conveyed to the hosj)ital of the 1st division. Sixth Corps, and, on December 19th, was sent to the 2d division hospital, Alexandria, Virginia. Haemorrhage from the facial artery, which occurred at various times, was controlled by compression and lint saturated w'ith persulphate of iron. He was discharged from the service on February 23d, 1863. He is a pensioner, his disability being rated three-fourths and permanent. The case is reported by H. W. Sawtelle, M. D. Ca.se. — 1st Lieutenant Thomas E. !Maley, 5th United States Cavalry, aged 29 years, was wounded at the engagement at Deep Bottom, Virginia, July 28th, 1864. An explosive ball entered the face beneath the right zygoma, and passing through, exjiloded in the left antrum of Highmore. He was admitted to the Ladies’ Home Hospital, New York City, on August 1st, 1864. Secondary haemorrhages occurred on August 18th, 22d, 23d, and 24th. He was prostrated from loss of blood. Pulse 105 and feeble. On August 24th, the right common carotid artery was ligated by Surgeon Alexander B. Mott, U. S. V. August 30th, ])atient doing well under generous diet and tonics ; jmlse 84. On September 10th, ligature came away. No recurrence of haemorrhage. He was granted leave of absence on October 4th, 1864, and was dropped from the rolls while on leave. On July 28th, 1868, Lieutenant ISIaley called on Assistant Surgeon George A. Otis, U. S. A., in reference to a ))lastic operation. He is not a pensioner. The case is reported by the operator. Case. — Private Joseph D. Norcross, Co. I, 9th Maine Volunteers, aged 40 years, w’as wounded at the battle before Petersburg, July 30th, 1864, by a conoidal ball, which passed through the superior maxilla. He was, on August 2d, admitted to Fort Monroe Hospital. Simple dressings were applied to the wound. On August 0th, he was transferred to New York, where he was admitted into the DeCamp Hospital, David’s Island. Secondary haemon-hage fi’om the jugular vein occurred August 14th, amounting to forty ounces of blood. Stimuhants and tonics were administered. Patient died August 15th, 1864. The case is reported by Assistant Surgeon Warren Webster, U. S. A. Case. — Private P. O’Connor, Co. F, 61st New York Volunteers, received, at the battle of Fair Oaks, June 1st, 1862, a gunshot wound of the oesophagus and a fracture of the ramus of the lower jaw, on the left side. He was, on June 8th, admitted to the South Street Hospital, Philadelphia. The wound of the neck had already healed. Repeated attempts at appo- sition of fractured portions of the jaw were made by means of ]>asteboard splints and Barton’s bandages. The patient was suft’ering with profuse salivation, which was attended with great thirst and a constantly increasing difficulty of deglutition. The dressings interfered with his efforts to quench his thirst, and were removed hy him at the first opportunity after their application. As the throat symptoms became more and more prominent, all treatment of the fractured jaw was abandoned. Secondary haemorrhage occurred June 12th, from the arteries of the throat, which was checked by a solution of persulphate of iron. Successive haemorrhages. Inability to swallow. Milk punch freely administered per rectum. Patient died of exhaustion June 15th, 1862. Post mortem showed that the ball entered on the right side of the neck, at the posterior border of the sterno-cleido- mastoid muscle, and passed behind the larynx and laid open the oesophagus, then turning at a right angle, penetrated the floor of the mouth, and passed out a little to the left of the mental symphysis, producing a fracture of the ramus of the lower jaw, on the left side. Case. — Private Albert W. Perry, Co. C, 1st Vermont Artillery, aged 24 years, was wounded at the battle of Cold Harbor, June 1st, 1864, by a conoidal ball, which fractured the facial bones. He was conveyed to the hospital of the 2d divisif)n. Sixth Corps, and transferred h}' steamer from White House Landing to Netv York, where, on the 15th, he was admitted to DeCamp Hospital, David's Island. Simple dressings were applied to the wound. Secondary haiinorrhage from the superior maxillary artery occurred June 18th, and recurred on the 20th, amounting to sixty-four ounces of blood. Patient died June 21st, 1864. The case is rej)orted by Assistant Surgeon Warren Webster, U. S. A. Skct. II.] OUNSITOT FRACXrRES OF THE FACIAL RONES. 353 Case. — Corporal John II. R , Co. II, 19tli Mniiu* VoluntocVs, aped 31 years, was wounded at tlie haltle of Spottsyl- vania. May l“2th, 18(54, by a conoidal ball, wliieli entered the nuiuth, producing a coniiniiiuted fracture of the alveolar process of the superior and fracture of the inferior maxilla; also lacerating deeply the right border of the tongue to the extent of two inches. He was on May 2Lst admitted to Finley Hospital, Washington. Simjile dressings were applied to the wound. Secondary hfflmorrhage from the internal carotid artery occurred May 28th, amounting to two ])ints of blood. Patient died May 2yth, 11564. The specimen is No. 207, Sect. I, A. M. M. The case is reported by Surgeon G. L. Pancoast, U. S. V. Case. — Corporal Isaac W. Patterson, Co. E, 19th !Maine Volunteers, aged 19 years, was wounded at the battle of Si)ott- sylvania, Virginia, May 10th, 1864, by a conoidal ball, which fractured the inferior maxilla and wounded the facial artery. He was conveyed to the hospital of the 2d division. Second Corps, and on May 16th he was admitted to the Lincoln Hosj)ital, Wash- ington. Secondary haemorrhage occurred, which was controlled by compression and persulphate of iron. He died May 21st, 1864. Assistant Surgeon J. Cooper McKee, U. S. A., reports the case. Case. — Private Wdliain Prater, Co. R, 48th Virginia Regiment, aged 23 years, was wounded February 6th, 1865, by a conoidal ball, which struck the middle of the right cheek, passed through the right ramus of the inferior maxilla, and ploughing through the tongue, fractured the left ramus at its angle; it then glanced, and emerged from under the left mastoid process. He was admitted to the Chimborazo Hosj)ital No. 1, Richmond, Virginia. On February 13th, secondary hemorrhage occurred from the lingual artery, at the root of the tongue, which was arrested by styj)tics. Case. — Sergeant Philip C. Quick, Co. H, 141st Pennsylvania Volunteers, aged 26 years, was wounded at the battle of Spottsylvania, May 12th, 1864, by a conoidal ball, which caused a compound fracture of the inferior maxilla, right side. He was on ^3ay ICth admitted to Lincoln Hospital, Washington. Secondary htemorrhage from the sublingual and the superior thyroid iirtery of the left side occurred May 18th, and recurred on the 19th, amounting to about sixty ounces of blood. In consetjuence of the laceration of the muscular structure, it was impossible to ligate in the wound; and after the luemorrhage occurred, the patient was too much debilitated to admit of ligating the carotid artery, which was the only alternative. As he opened his mouth with great difiiculty, enemas of beef tea and brandy were administered every three or four hours. Lint, saturated with a solution of chloride of iron, was constantly apjdied to the wound. He died May 19th, 1864. The case is reported by Assistant ISurgeon J. C. McKee, U. S. A. Case. — Private Frastus Ranger, Co. E, 32d Maine Volunteers, aged 26 years, was wounded at the battle of Petersburg, Virginia, July 6th, 1864, by a conoidal ball, which entered one and a half inches below the angle of the lower jaw, left side, passed obli(|uely across the neck, and emerged two inches to the right of the symphysis, comminuting the bone in its course, and injuring the thyroid cartilage. He was conveyed to the hospital of the 2d division. Ninth Corps, where several fragments of bone were removed, and on the 16th admitted to Mower Hos])ital, Philadelphia. Simple dressings tvere applied. On July 19th, hmmorrhage occurred, supposed to come from the lungs. On J uly 21st, profuse htemorrhage took i)lace from the mouth, nose, and both wounds, and death resulted on the same day. Post-mortem examination revealed the inferior thyroid and lingual arteries severed by the ball. Surgeon Joseph Hopkinson, U. S. V., reports the case. Case. — Private William Reeves, Co. C, 76th New York Volunteers, aged 22 years, received, at the battle of the Wilder- ness, Virginia, May 6th, 1864, a com})ound comminuted fracture of inferior maxilla b^^ a conoidal ball, which entered the left cheek half an inch anterior to the angle of the jaw, and emerged at a point nearly opposite. He was conveyed to a field hospital, where a large number of splinters were removed through the mouth and aperture of exit. He was admitted to the Stanton Hospital, Washington, on May 11th, 1864. Aperture of entrance small; that of exit about three inches in its longest diameter. On May 12th, secondary haemorrhage occurred. He lost about twenty-four ounces of blood, and was much exhausted. On the same day, at five o’clock r. M., the left common carotid artery was ligated by Assistant Surgeon George A. IMursick, U. S. V. No anaesthetic was useil. Patient did not rally after the operation. He died on May 13th, 1864, at four o’clock a. m., from exhaustion. The autopsy showed the haemorrhage to have occurred from the lingual and inferior dental arteries. The case is reported by the operator. Case. — Private John R , Co. B, 63d New Y'ork Volunteers, aged 30 years, was wounded at the battle of the Wilderness, May 5th, 1864, by a conoidal ball, which fractured the inferior maxilla ami divided the carotid artery, and lodged behind the tonsil. He was, on May 13th, admitted to Finley Hos- jiital, Washington. Successive hsemorrhages from the internal wound in the fauces occurred May 14th, amounting to one pint of blood. Cold water dressings were ap]died to the wound. On May 31st, frag- ments of bone were removed, and the comfiion carotid artery was ligated below the right omo hyoid muscle by Surgeon G. L. Pancoast, U. S. V. The patient died June 1st, 1864, from secondary luxunorrhage. S))ecimens of the common carotid artery and inferior maxilla were contributed to the museum by the operator, and are Nos. 2481 and 2482. C.vSE. — Private Lemuel Reccord, Co. A, 7th Indiana Volunteers, agtsl 24 years, was wounded at the battle of the Wilderness, May 9th, 1864, by a conoidal ball, which entered the nostril, right side, and passed out at the neck, fracturing the lower jaw. He was on the same day conveyed to the hosjiital of the 4th division. Fifth Corps, and transferred to Alexandria on May 12th, where he was admitted into the 2d division hosjjital on the 14th. Simple dressings were applied to the wound. Secondary limmorrhage from the transverse facial artery occurred May 30th, and recurred on the 31st, amounting to twelve ounces of blood. Styptics were ap]ilicd. Patient died .June 2d, 1864. The ca.se is rejiorted by Surgeon Fortion of the i)rimitive carotid and its branches from the left side. He was admitted to the 3d division hospital, Alexandria, the next day; an aneurisinal tumor had formed. The case did well, except that there was a hard circumscribed swelling beneath the left ear. On August 4th, a hmmorrhage occurred from the wound of entrance, which was controlhnl by a graduated compress, but which was gradually succeeded by a swelling which extended from the mastoid process to the clavicle, and which was caused by the escape of blood into the tissues of the neck. Frequent haemorrhages occurred from the wound in the mouth, which could not be controlled but by compression on the loft carotid. The compression on the veins of the neck induced great oedematous swelling of the face, the left eye was closed, the tongue hung from the open mouth, and articulation became impossible. The haemorrhage from the mouth having returned about 5 A. M., on August 11th, compression was made over the carotid, when the patient appeared to have drawn into his glottis a clot of blood, during an effort at inspiration. Apncea ensued, followed in a few moments by death, his strength being entirely exhausted by his losses of blood and rest, and his continued suffering. At the autopsy the left skid of the neck was found dis- tended by effused blood. The internal carotid was uninjured, but the external was lost in the tumor, which seemed to be a true aneurism undergoing consolidation. Behind the pharynx was found a quantity of dark fluid blood. In the right ventricle of the larynx was found a soft clot, which was the immediate cause of death, since it acted as a valve permitting of expiration, but ju’eventing inspiration. A.ssistant Surgeon 11. Lawrence Sheldon, U. S. A., decided against an operation, as he could not s.atisfy his mind as to the source of the haemorrhage. The jjathological specimens, consisting of a part of the lower jaw and a portion of the primitive carotid and its brancheo exhibiting a tumor, were contributed to the Army Medical Museum, with a history of the case, by Assistant .Sur<;eon William 'I’homson, U. S. A., and are numbered 4923 and 4925 of tiu' Surgical Section. Sect. II.] GUNSHOT FRAOTUEES OF THE FACIAL HONES. 355 Casio. — Private' Saunie-l Stieiitx'rgc'r, 1st Unitod States Cavalry, was wouiide'd at tliu battle (if Willianislnirg-, Virginia, May Ctli, 186:2, by a imiski^t ball, wbich enitered to tbo left of the symphysis of lower jaw, fractured tlu' boue and carried away several teeth, a part of the tongue, and posterior wall of pharynx. lie was unable to swallow nonrislnnent, without the greatt'st distress and difficulty. Swelling of injured parts; copious boemorrbage. lie was admitted to the llygeia Hospital, Fort Mon- ' roe, Virginia, (jn May 9tb, 1862. On May 13tb, re'moval of ball and sevc'ral teedli from absce.'s aboi’e clavicle. May Kith, coiiious baemorrbage from wound. Snlidiuric ether was administered, and the common c.arotid artery was ligated by Surgeon Heed H. Hontecou, U. S. V. Seven days after ligation, batmorrbages from wound from which ball was e.xtracted; an unsuccess- ful attempt was mad^ to find the bleeding point. He died on May 23d, 1882, from exhaustion from bmmorrliage. Antojisy indicated that the ball bad fractured the transverse jirocess of the third cervical vertijbra. The vertebral artery had worn against the spicula thus produced, and hence the second hannorrhage. The ciise is reported by the operator. C.VSE. — Private George W. Scales, Co. B, 54th Indiana Volunteers, was wounded at the battle of Vicksburg, IMississipjii, December 29th, 1862. The missile entered the mouth, knocking in the front teeth of the upper and low(>r jaw, and lodged in the neck below and behind the mastoid process. He was conveyed to the hosjiital of the 3d division. Thirteenth Corps, where he remained until .laniiary 8th, 1833, when he was t.aken on board tbe hospital transjiort City (jf Memphis. On January 9th, secondary haemorrhage occurred, which was anvsted by the .aiiplicatiou of jiersidjihate (jf iron. On January 13th, he was admitted to hospital at Paducah, Kentuck 3 ', and discharg(‘d from service .Tidy 5th, 1863, for aneurism of the left e.xternal carotid arterv. The case is reported bv Surgeon H. P. Stearns, U. S. V. On MaJ’ 19th, 1838, Pension Examiner W. A. Clapii reports that mastication is difficult, as well as deglutition, from injniy to tongue. He rates his disabilitj' total and permanent. ^ Ca.se. — Captain Jacob Schwartzlander, Co. D, 104th Pennsjdvania Volunteers, aged 32 v'ears, was wounded at the battle of Fair Oaks, Virginia, May 31st, 1832, bj' a conoidal ball, which entered the inferior maxilla, right side, in front of its angle, jiassed through the tongue about one inch behind its apex, and emerged through the inferior maxilla of left side, higher up .and somewhat back of the wound of entrance, fracturing it. In its course, it shattered tbe jaw at point of entrance, removed several lower and one upper molar tooth, and lacerated the tongue so that the anterior part protruded from the mouth. The b.all evidentlj' struck with its side, its axis parallel to the cheek, and turned, in its course, so as to make its exit with its apex forward. The wounds, wbich lik'd jirofuselj', were dressed with lint and adhesive strips. He became weak from lo.ss of blood, .and was convej'ed to Savage Station, where the wound was redressed. There was .some haemorrhage during the night, but not much pain, .and the tongue so much swolk'ii as to protrude from the mouth .and prevent deglutition. He was conveja'd to the hospital transport W. Willidin, for transfer to Philadelphia. On June 1st, several spicula; of bone and some teeth were removed, the tongue was replaced : o far as tumefaction would allow, the fracture adjusted and pasteboard splint aiuL bandage applied. He was unable to take nourishment until June 2d, when beef tea was administered by a tube through the nostrils. He was admitted to St. Joseph’s Hospittd at Philadelphia, June 4tb, at which time he could not articulate, deglutition was still difficult, the wounds were suppurating freelj’, the tongue was .sloughing, the discharge being veiy fetid, and the general strength much reduced. Several spiculse of bone were extracted, and the lacerated and protruding tongue was removed hy lig.ature, which came away in three weeks. lie was fed for eight weeks through a tube, the mouth and fauces were syringed with watiu- every two hours, and external apjilications of a solution of suljihate of copper were made. About August 24th, he was able to articulate distinctlv'. The tongue was gradually filling up. He was able to eat eveiy kind of food. The deformity of jaw was disappearing, and there was givat mobility. He was returned to dut^'. Not a pensioner. C.wsE. — Private Anthony Surbe, Co. C, Gtli Iowa Volunteers, aged 22 j-ears, was wounded at the battle of Dallas, Georgi.a, May 2()th, 1834, by a conoidal ball, which fractured the lowi'r jaw, .and escaped near the left angle of the mouth. He was admitted to the hospital of the 4th division. Fifteenth Corps, thence convej'ed to the field hospital, Chattanooga, Tennessi'c', where he was admitted on June 4th. Tonics, stimulants and nourishing diet ordered. Secondary ba;morrhage from the right external carotid artery occurred June .5th; loss of blood, one pint. Iltemorrhage recurred on tbe 7th, the loss of blood amounting to three (piarts. Patient died June 7th, 1834. The case is reported by Assistant Surgeon C. C. Bj’rne, U. S. A. C.VSE. — Private William Wolf, Co. K, 7th New York Heavy' Artilleiy, aged 30 years, was wounded at the battle of Peter.s- burg, April 7th, 1835, ly a conoidal ball, which entered the lower jaw, near the right angle, ji.assing directly' through, producing a compound comminuted fracture of the inferior maxilla, and lacerating almost from ear to e.ar. He was on April 15th admitt( (l to 1st division hospital. Annapolis, Maryland. On admission the patient was feeble .and anmmic, having from time to time lost considerable blood; the wound was looking badly and V’ery offensive; the jaw was veiy much shattered, many of the fragments being imbedded in the clmek, others hanging loosely through the opening below the chin ; every tooth was carried away, and altogether the wound was frightful. The jiower of utterance was gom;, and it was with difficulty' he could swallow, most of the food passing through the opening below. lie improved up to the 23d, when secondary' hsemorrhage from the sub-maxillary', lirobably the facial artery, occurred April 23d, and recurred on the 27th, amounting to’tvventy-four ounces of blood, whicb was controlled by pressure upon the right carotid artery and the ajjplication of tincture of muriate of iron. After the hoemorrhage on the 27th, his case became hopeless. The patient died April 30th, 1805. The case is reported by Surgeon B. A. Vander- kieft, U. S. V. Case. — Qu.artermaster Sergeant Amos Whitney, Co. C, .5th New York Heavy Artillery, aged 39 years, was wounded at Snicker's Gap, .July' 18th, 1834, by a conoidal ball, which pi'oducc'd a transverse fi’actiire of the lower maxilla. He w!is, on .Inly 22(1, admitted to Sandy Hook Hosjiital, Maryland, and transferred on the 27th to Frederick City Hospital, wheri; he was admitted the same d.ay'. Simple (lr(;ssings were aiijilied to the wound. Secondary h.aunorrhage from the facial artery occiiired July 31st, amounting to sixty-four ounces of blood. Patient died .July 31st, 1834. The case is repoi-ted by Assistant Surgeon H. F. Weir, U. S. A. C.v.SE. — Lieut(‘nant Thomas We.stcott, Co. K, 8lh New York Heavy Arlilh'ry, tiged 23 y'e.ars, was wounded at the battle of Cold Harbor, June 1st, 1834. by a conoidal ball, wbich fractured the left superior maxilla. 'I'he missile entered the left side 356 WOUNDS AND INJURIES OF THE FACE. [Chap. II. (if the nasal cavity, jiassed througli the levater muscle, and lodged in the stenio-eleido-niastoid muscle, lie was conveyed to the hospital of the 2d division, Second Corjis. On the 4th, he was admitted to Si'ininary Hospital, Georgetown, where Acting Assistant Surgeon J. M. McCalla administered chloroform and extracted the ball from the left side of the trapezius muscle. Cold water dressings and flax-seed poultices were applied to the wound. The a]ipetite was jioor, and the patient .suffered much from loss of sleep. On tlio 2r)th, he was transferred to Daltimorc, and admitted into the Newton University Hospital. Secondary hiemorrhage from the internal maxillary artery occurred June 29th, and recurred the same day and on the 30th, amounting to fourteen ounces of blood, which was controlled by pressure. On September 24th, he was transferred to Annajiolis, where he was admitted into the 1st divi.sion hospital. He was discharged the service October ICth, 18C4. The case is' reported by Surgeon E. JIcDonnell, U. S. V. He is a ]>ensioner; his disability is rated total and probably permanent. Ca.se. — Private George T. A , Co. E, 3d North Carolina Infantry, was wounded at the battle of Gettysburg, July 3d, 18G3, bv a colloidal musket ball, which fractured the right lower jaw. He also received a wound of the neck. He was taken prisoner and treated in field hosiiital until July 10th, 1833, when he was admitted to the Newton University Hospital, Baltimore, Maryland, where fragments of bone w'ere removed from the body of the right lower jaw, halfway between chin and angle, and the [larts coaptated. Barton’s bandage was applied, with cold water dressings. Mild saline cathartics were given, and nourish- ing licpiid diet ])rescribed. He imjiroved rapidly, and on July Kith was transferred to the Chester Hospital, Pennsylvania, whence he was transferred, on September 17th, to City Point, Virginia, for exchange. He was afterward admitted to Hospital No. 1, Kichmond, Virginia, and, on September 25th, 1833, furloughed for forty days. The pathological specimen, consisting of three fragments of bone and a molar tooth, was contributed to the Army Medical Museum by Surgeon C. \V. Jones, U. S. V., and is numbered 1391 of the Surgical Section. Case. — Private Henry C. , Co. F, 30th North Carolina Infantry, received a gunshot wound of the face at the battle of Antietam, Septcanber 17th, 1832, the entire lower jaw' being shot away to points within one inch and a half of the angles. He was admitted, on October 18th, to Hospital No. 5, Frederick, where death resulted, on December 17th, 18G2, from exhaustion and inanition. The pathologic.al specimen consists of the inferior maxilla. An irregular plate of new bone measuring two inches in length, three-fourths of an inch in width, and half an inch in thickness, has formed anteriorly, and is connected to the rami on either side by ligamentous bands. It was contributed to the Army Medical Museum by Surgeon H. S. Hewit, U. S. V., and is numbered 1162 of the Surgical Section. Case. — Private John Baker, Co. I, 9th Pcnn.sylvania Eeserves, aged 19 years, was wounded at the battle of Charles City Cross Koad.s, Virginia, June 30th, 1832, by a conoidal ball, which entered at the left angle of the mouth, fractured the npj)er ja\’\^ cut the tongue h.alf in two, and emerged at the angle of the right lower jaw, fracturing it and displacing the teeth. He n^ceived also a bayonet wound in the lower jiart of the back, which penetrated the left thigh. He was admitted into the Satterlee Hospital, Philadelphia, on July 26th, 1832. On the same day. Acting Assistant Surgeon Edward A. Smith removed several ideces of loose bone. Cold w'ater dressings were a])plied, and the jaw was kept closed. Fluid diet was ordered. As the bone became loosened it was removed from the inside until almost the entire right side of the inferior maxilla became detached. Then the outer wound healed, the jaw became gradually stiffened until February 3d, 1863, at which time he was able to chew food of some consistence, and sutt'ered but little. He had neuralgic pains at times, and some deterioration of the facial angle; his health was good. He was discharged the service (jn A])!'!! 14th, 1863. The case is reported by the operator. On November 17th, 1869, I’ension E.xaminer .S. Logan reports that Baker’s leg is jiaralyzed and atrophied, resulting from the bayonet wound, and that his disability is permanent. Case. — Second Lieutenant Nelson Crockett, Co. A, 55th Ohio Volunteers, aged 37 years, was wounded at the second battle of Bidl Run, August 30th, 1832, by a conoidal ball, which entered the left side of the inferior maxilla, two inches from the angle, fractuilng it at this point, then passed across beneath the tongue and emerged on the right side from the inferior maxilla, fracturing this also at a point one inch and a half from the symphysis. He was conveyed to Alexandria, Virginia, and admitted into the 3d division hospital on August 31st, 1862. The fractured portions of the bone were secured at the two extremities by silver wire, and Barton’s apparatus was applied. The patient was discharged the service on April 4th, 1863, the union of the bone being imperfect. The case is rejiorted by Surgeon Edwin Bentley, U. S. V. On April 5th, 1868, Pension Examiner H. Frasse reports “the fracture is imimited, interfering with the patient’s speech, and disables him from masticating solid food.” Hu rates his disability total and permanent. Case. — Private Michael Donhouser, Co. 11, 10th United States Inftmtry, aged 25 years, was w'ounded at Gettysburg, Jidy3d, 1863, by a conoidal musket ball, which fractured both rami of the inferior maxilla at the angles. Several teeth were carried aw'ay and the tongue injured. The haimorrhage was .sev'ere. He was treated in field hospital until Septdiiber 26th, 1883, when he was transferred to St. Joseph's Hospital, Central Park, New York. On admission, the j.iw was imperfectly united by fibrinous exudations on both sides. Aiticulation was destr(.)yed. On October 1st, a small s])iculum of bone was removed, internally, from the left side of the jaw'. By November 19th, the wound having healed, he was transferred to the post hosjdtal at Fort Columbus, New York Harbor, whence he was discharged on December 16th, 1863, on account of complete aphonia from injury to the tongue. He is not a j)ensioner. Case. — Lieutenant William E , 17th United States Infantry, was wounded at the battle of Getty.sburg, July 2d, 1863, by a conoidal ball, which entered the left side of the face, shattering the body of the inferior maxilla, and emerged beneath the ramus of right side. He wa.s, on the next day, admitted to the Seminary Hos])ital, Gettysburg, and on July 8th, transferred to Newton University Hospital, Baltimore. On .admission, he w'as much enfeebhxl, and the wound was in very bad condition. Surgeon C. W. Jones, U. S. V., at once removed the fractured portions of bone and two molar teeth from left side of body of the inferior maxilla, syringed the wound, chaned the mouth with tincture of myrrh, applied a dressing of lint saturated with a solution of chlorinated soda, and secured the jaw by Barton’s bamhige. Stimulants and nourishing diet were given. Under this treatment the patient rcacte(l rajiidly. and continued to improve st(*adily. In thirty-six hours he could converse intelligibly; Sect. II.] GUNSHOT FRACTUHES OF THE FACIAL BONES. 357 subsequently yeast anil charcoal poultices v. ere a])i)Ueil to the wound, which left it clean, with healthy granulations, and he was granted a leave of absence on July 14th, 1833. On January 23d, 18(14, he was admitted to the 1st division hospital at Annapolis ; the wounds had closed with but slight deformity ; the tongue was pai-tially paralyzed. He was returned to duty on February Cth, 18C4. The pathological specimen, consisting of tune small fragments of bone and two molar teeth, was contributed to the Army Medical Museum by the operator, and is numbered 1689 of the Surgical Section. A fang of one of the teeth is broken off and remains in the .socket, which forms part of the largest fragment. The fragments correspond to about one inch of the body of the bone. He is not a pensioner. Case. — Private Patrick Gibney, Co. B, 31st New York Volunteers, aged 19 years, received a gunshot wound of the face at Chancellorsville, Virginia, on May 3d, 1863, the missile entering at right alse nasi and emerging near the right angle of the lower jaw, which it fractured. He was treated in field ho.spital until May 9th, when he was admitted to Harewood Hospital, Wash- ington. Simple dressings were applied to the wound, and the fractured parts kept in position. He recovered, and was discharged on May 25th, 1863, his tenii of service having exjiired. He is not a jjensioner. Case. — Private Robert Goldsnuth, Co. A, 107th New York Vidunteers, aged 23 years, was wounded at Antietam, September 17th, 1862, by a conoidal ball, which entered in front of the syinphj’sis of the right inferior maxilla, passed obliijuely backward beneath the tongue, then downward and backward, and lodged in the scapula just above its spine, fracturing the maxilla at the symphysis and the angle. The ball was cut out on the field. Considerable limmorrhage followed immediately after the injury, with complete paralysis of the right arm. He was conveyed to Philadelphia, and admitted into the Broad and Cherry Streets Hospital on September 26th, 1862, when Ins arm was still paralysed, the tissues around the jaw swollen and inttamed, and the wounds discharging freely. The left fragment, at the symjihysis was displaced backward and slightly down- ward. The patient’s general condition was good. The wounds were dressed with a flaxseed poultice, a Barton's bandage was applied to the head, and extra diet was ordered. On November 12th, rapid improvement had taken ])lace, the paralysis having almost entirely disappeared. The wound, made by removing the ball, had entirely closed; the wound of entrance was still discharging slightly. One fragment of bone W'as removed from the symphysis ; the union was firm. The deformity existing at the time of his admission into the hospital still existed to a slight extent. On December 11th, 1862, he was transferred to the Cuyler Hospital at Germantown, where he w’as discharged the service on January 6th, 1863. The case is rejiorted by Surgeon John Neill, U. S. V. The patient is a pensioner, his disability being rated one-half and permanent. Case. — Private Robert Jeffery, Co. F, 126th New York Volunteers, was wounded at Gettysburg, July 3d, 1863. While lying on his breast, with his head raised, a ball struck him on the front of the nose, on a tine with the internal cauthus, fracturing the nasal bones, and, passing downward through the left antrum, the hard jialate, and left side of the tongue, opposite the last molar tooth, came out on the left side of the neck, opposite the upper border of the thyroid cartilage. The wound bled freely for a short time. He was treated in fteld hospital until July 13th, when he was admitted to the Broad and Cherry Streets Hospital, Philadelphia. Several small spicnlae of bone had been removed. The patient’s general condition was good. Simple dressings were applied, the mouth was frequently w'.ashed wdth a solution of borax, and a fluid diet was ordered. Under this treatment he improved rapidly. A few days after admission, several small fragments of the nasal bones were removed, and by August 1st the wound of entrance had entirely closed, occluding the left nostril. The wound through the hard palate had diminished in size, leaving a fistulous opening communicating with the left antrum; that of the tongue had cicatrized and was adherent to the side of the jaw’ by false adhesions, and traumatic paralysis was so well marked that in attempting to jirotrude the tongue it was strongly drawn to the left side; his articulation w'as slightly impaired. A slight discharge still continued from the wound of exit, but the patient had made a rapid recovery, with slight deformity, considering the nature of the injury. He was dischargi'd from serv'ice on January 19th, 1864, and pensioned. Pension Examiner H. A. Potter reports, Ajuil 11th, 1864, that “ the sense of smell and taste are gone and the voice much impaired. He has difficulty in deglutition, and much prostration on slight exertion. It seems to be on the left side. The pneumogastric nerve must be involved in some way. The left side of the tongue is paralysed.” Case. — Private R. R. Kates, Co. H, l*2th New Jersey Volunteers, aged 22 years, was wounded at Chancellorsville, Jlay 3d, 1833, by a musket ball, which entered the mesial line of the upper lij), carried away almost the entire superior maxilla of that side, and emerged about two inches behind the left ear. He was taken to the hosjiital of the 3d division. Second Corps, and, on May 8th, transferred to the Douglas Hospital, Washington, where fragments of bone were extracted. There were some pieces of bone deeply imbedded in the neck, and small fragments were daily discharged from the mouth. On June 8th, a tooth was extracted from the neck behind. He was furloughed on June 26th, at which time the posterior wound had healed; the iqiper portions of the bone were still inflamed ; he could swallow easily, but spoke indistinctly. He was returned to duty on September 29th, 1863. His name does not ajipear upon the Pension Roll. Case. — Private .lames Kelly, Co. I, 3Lst New York Volunteers, aged 26 years, was wounded at the battle of Gaines’s Mill. Virginia, .Itine 27th, 1862, by a conoidal musket ball, which entered near the middle of the angle of the left lower jaw, splintering the outer wall of the maxillary bone, jiassed downward, across the neck, between the trachea and the oesiqihagus, fractured the right clavicle, and lodged beneath the lower edge of the jiectoralis major muscle. He lay on the battle-field all night, and was taken, on the next day, to Ravage Station, where he remained a day and a night, when, feaiful of being taken prisoner, he walked to Harii.son’s Landing, a distance of twenty miles. On .July 1st, he was sent to Fort Monroe, where a liiece of dead bone w.as removed from the jaw. On .July 2d, he was transferred to J’hiladelphia, entering Salterlee Hospital on the 7th. When admitted, his general health was good. An ojjeidng at the point of entrance of the ball being explored liy means of ti probe, loose [lieces of dead bone were I'eadily felt. The inobe, a very large ball-headed one, was passed down along the track of the ball to the furrow marking the junction of the trachea and lesophagus. The passage between these had healed up. The patient stated that, for .several days aftei- the reception of the injury, he had considerable difficulty in swallowing. A large swelling existed at the right side of the neck, and, on July 9th, fluctuation being perciqitible, an opening was made at 358 W0UN])S AND INJUKIES OF THE FACE. [Chap. II, its most pniniiiieiit iioint, about tlie middle of tlie neck. On July lltli, the 1)011 being distinctly felt under the lower edge of the })ectoralis majoi' muscle, Acting Assistant Surgeon John H. Packard made an incision and removed it without difficulty. The swelling at the side of the neck soon diminished, and the orifice made on .Inly 9th came down so as to he on a level with the claVicle, large portions of which were removed from time to time, and fragments of the jaw also came away through the wound made by the entrance of the hall. The opening by which the hall was extracted healed up very readily. There was considerable swelling near the middle of the right clavicle, owing to a deposit of new hone. A small opening existed at the orifice of entry, and a sinus extended down toward the lower edge of the jaw, hut no dead hone could he felt. The patient recovered, and was discharged from service on FThruary hth, 1863. He is not a pensioner. * Cask. — Private F'rancis H. Kirker, Co. E, 100th Pennsylvania Volunteers, aged 20 years, was wounded at Bull Pun, August 29th, 1862, by a small ride hall, which entered on the left side of the nose, at the junction of the nasal hone with its cartilage, and, ])assing obliquely across and slightly backward, emerged one inch above the angle of the lower jaw, on a vertical line with the external meatus, tearing away a i)art of the lobe of the ear. Fie was conveyed to Washington, entering George- town College Hospital on September Cth ; on FAbrnary 4th, 1863, lie was transfen-ed to Broad and Cherry Streets Hospital. He stated that the wound bled freely at intervals for several days, and that several small jiieces of bone had been removed. On admission the wound of entrance and exit had healed. There was partial paralysis of the muscles of the right cheek and some deafness on that side from injury to the nerves. There was slight ptosis of ujiper lid and partial loss of vision in the right eye. The ophthalmoscope revealed a congested state of the retina. He was discharged from service on March 19th, 1863, and pensioned. I’ension Examiner A. II. McClure reports, Ajiril Cth, 1867, that there is necrosis of the su])erior maxilla, and that the pensioner is unable to peiform any labor without causing pain. Case. — Private John McNallcy, Co. H, 81st Pennsylvania, aged 23 years, was wounded at Fredericksburg, Virginia, December 13th, 1862, by a round musket ball, which entered on the left side of the nose, on a line with the internal canthus of eye, fractured the nasal bone, and, passing obliquely across, fractured the right superior maxillary bone and j)enetrated the cheek opposite the second molar tooth, in its course giving rise to a fistula lachrymalis on the right side. He was at once admitted to the ho.spital of the 1st division. Second Corps, .and, on December 20th, sent to Cathariny Street Hospital, I’hiladelphia, whence he was transferred, on FAbruary 2d, 1863, to Broad and Cherry Streets Flosjjital. When admitted, both wounds had closed, with little depression at the wound of entrance. The right cheek was consider.ably swollen. The hstula had almost healed, and closed a few days after admission. The patient stated that the wounds bled very freelj', at intervals, for the first twelve hours, and that several small })it'ces of bone were removed on admission to Catharine Street Hospital. He conqilained of partial loss of vision. The ball of the eye was slightly atrojihied, and its jaipil considerably larger than the other, and irregular and .slow in action. An examination with the ophthalmoscope showed the vessels of the retina to be in a congested condition. He was discharged from service on iMarch 31st, 1863. He is not a pensioner. Case. — Private AVilliam Madison, Co. H, 118th lAnnsylvania Volunteers, aged 46 years, was wounded at Blackffird’s FArd, September 20th, 1862, by a conoidal ball, which entered just in front of the coronoid process, on the left side, passed through the cheek and .soft p.alate, and emerged on a line with, and about one-half an inch below, thelobeof the right car, tearing away the uvula and the lateral half arches and fracturing the ramus of the jaw on the right side just above the angle. He was conveyed to Philadelphia, and admitted into the Broad and Cheriy Streets Hospital on Sej)tember 27th, 1862. The patient stated tliat, immediately after the injury, he suffered from loss of blood, and before le.aving the field the surgeon removed some tissue from his mouth. On his admission into the liosj)ital, the right cheek was swollen and inflamed, and both wounds were discharging slightly. The uiiper fragment of the bone was disj)laced, backward and inward ; the parts within looked very well. The right side was dressed with a flaxseed poultice ; the left side with a warm water dressing, and a Barton’s bandage was lightly aj)plied. Extra diet in a liquid form was ordered. The patient comi)lained of a loss of sensation in the right half of the lower rq), owing to a division of the inferior dental nerve at the seat of the fracture. He improved rapidly, and on November 1st, 1862, was convalescent, the wound of entrance having closed, the wound of exit discharging slightly, and the, bony union firm. He was transferred to the Veteran Reserve Corps on x\pril 21st, 1863. The case is reported by Surgeon John Neill, U. 8. V. On December 13th, 1865, Pension Examiner E. A. Smith reports that the sense of taste is destroyed, tongue jiaralysed on the left side, and hearing in right ear and sense of smell are much im])aircd. He rates the disability three-fourths and jn-ohably })ermanent. Case. — Sergeant Alfred Malone, Co. K, 6th West Virginia Cavalry, aged 39 years, was wounded at Springfiehl, Virginia, June 26th, 1864, by a pistol ball, wljich entered the left cheek one inch and a half from the angle of the mouth, on a line with the external canthus of the left eye, passed horizontally beneath the nares, and emerged two and a half inches from the right angle of the mouth, on a line with the meatus anditorius externus, fracturing both sides of the superior maxilla. One molar and two bicuspid teeth on the right side were removed by the patient himself at the time of the injuiy. He was admitted, on the next day, to the hospital at Cumberland, Maryland. When admitted the incisors and canine teeth, attaclied to a fragment of the superior maxilla, were lianging loosely between his lips; the left bieusi)id teeth were displaced, and the root of the left canine tooth was cut otf and remaining loose above the fracture. A very ofiensive foetid odor accompanied the discharge from the wound. Several fragments of bone had come away by snp])nration, and others were exposed, but so attached to the muscular tissue ns to in-event their removal without danger of hasmorihage. The anterior })alate was cut tln-ough and hung pendulous in the month. The bleeding was free at first, but was conqdetely arrested by cold water a]iplications. The fractured teeth and maxilla were placed in position with as much care as possible, and supported by a tin splint so formed as to fit over the upper lip and beneath the superior incisors, and held in position by a T bandage. The mouth was ch>ansed with a weak solution of chlorinated soda, and resin cerate ajiplied to the wounds of the cheeks, with stimulants and nourishing diet internally. I’nder this treatment the i)atient rallied, and on July 1st, the bad odor had ceased; healthy granulations were forming rapidly. Several fragments of bone had been discharged. On July 22d, the patient's health was good. The wound Sect. II.] GUNSHOT FKACTUHES OF THE FACIAL BONES. 359 through th(^ superior maxilla had .so far united as to hold up the fragment of bone and teeth without the aid of the sjdint. He was furloughed on July 22d, 18'o4. While at home an abscess ])ointed through the right cheek, between the -wound of exit ami the angle of the mouth, which discharged pus freely and several spicuhu of bone, among them a fragment of the liard ])alate, one-half inch long. By September 2'2d, the wound of the left cheek had entirely liealed. A small discharge still continued from the wound in the right clieek. The upper incisors and bicuspids were held in place by union of the soft parts, but were not sufficiently solid to uSt> in chewing. He was transferred to the hospital at Grafton, on September 25th, and returned to duty on October 15th, 1804. He was discharged on May 22d, 1866, and pensioned. Pension Examiner E. D. Salford reports, Octola r 28th, 1868, that “the hones have never united, and he has no ability to chew food, and is a great suft'erer from facial neuralgia in consequence of the injury.” , Case. — Corporal Jacob M , Co. G, 20th Michigan Volunteers, aged 29 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 18.64, by a conoidal musket ball, which fractured the right lower jaw. He was taken to the hosiiital of the 3d division. Ninth Corps, and, on June 8th, admitted to the Emory Hospital, Washington. On June 10th, Surgeon N. K. Moseley, U. S. V., removed several fragments of bone from the inferior maxilla. Simple dre.ssings were applied, and, on August Cth, he was tramsfern'd to St. Mary's Hospital, Detroit, and, on October 14th, to Harper Hospital, where death resulted on December 7th, 1864, from -wound, complicated with Inemorrhage of the lungs. The pathological specimen, consisting of seven pieces of bone, to which a small flattened jiiece of the missile is attached, was contributed to the Army Medical Museum by the operator, and is numbered 2507 of the Surgical Section. Case. — Private William T. Moore, Co. G, 15th Massachusetts Volunteer.s, was wounded at Gettysburg, July 2d, 1863, by a conoidal ball, which entered the buccal muscle of the left side of the face, passed slightly upward and emeiged on the right side of the face, knocking out three teeth of the left upper jaw, and fracturing the right tipper jaw. He was at once admitted to the hospital of the 2d division. Second Corps; thence sent to Baltimore, and, on July 10th, 1863, admitted into the Newton University Hospital. Immediately after admi.ssion, a fragment of the alveolar process of the right sujierior maxilla, containing one canine and one bicuspid tooth, was removed. The parts were then coaptated. Barton’s bandage applied with cold water dre.ssings, and liquid diet given. On J uly 3l6t, he was nearly well, and his general condition was excellent. He was trans- ferred to the Veteran Keserve Corps on October 20th, 1863. The pathological .specimen is No. 1690, Section I, A. M. M., and was contributed, with the history, by Surgeon C. W. Jones, U. S. V. This man is a pensioner; his disability is rated one- half and permanent. Case. — Private Madison B. Moss, Co. I, 23d Pennsylvania Volunteers, aged 31 years, was wounded at Fair Oaks, Virginia, May 31st, 1862, by a conoidal ball, which entered ])osteriorly, just below the right condyle of the lower jaw, and, passing obli(juely forward and across, emerged at the left angle of the mouth. Most of the ramus of the right side was carried away ; the lip was lacerated, and a part of the tongue on the right side, with several teeth, and their alveoli, on the left side at the point of exit of the ball, were wanting. The patient remained on the field two daj's, very much prostrated from the loss of blood. He was afterward removed to a j)rivate house ; thence to Norfolk, Virginia, where he remained for three weeks, when he was sent to New York, and thence to Philadelphia, .and admitted into the Broad and Cherry Streets Hospital on October 3d, 1862. The patient stated that the only dressing applied was lint wet with cold water, and the mouth w-as well syringed daily. His diet consisted of beef-tea and an’ow-root. During the treatment, several pieces of bone were removed from the wound. On his admission into this hospital, the wound of the right cheek had .almost cicatrized, leaving a deep scar, which extended from the ear to the angle of the mouth. The wound on the left side had entirely he.aled. His health was good, but he is unable to take solid food. The deformity of the soft places was such that a benefit would ))rohably result from a plastic operation. On J.anuary 14th, 1863, the patient was transferred to the Mower Hospital, Philadelphia, where he was discharged the service on January 19th, 1863. The case is reported by Surgeon John Neill, U. S. V. The patient is a pensioner, his disability being rated total and permanent. Case. — Private Michael Murphy, Co. G, 69th New York Volunteers, aged 24 ye.ars, was wounded at the Wilderness, Virginia, May 5th, 1864, by a conoidal ball, which caused a lacerated wound of the face, injured the palate, and comminuted the upper jaw. He was taken to the hospital of the 1st division. Second Corps, where detached pieces of bone were removod by Surgeoii Wm. O’Meagher. On May 11th, he was transferred to Judiciary Square Hosj)ital, Washington, whence he was returned to duty on July 12th, 1864. He is not a pensioner. Ca.se. — Private Peter Kafferty, Co. B, 69th New York Volunteers, was wounded at the battle of Malvern Hill, Virginia, July 1st, 1862, by a conoidal ball, which entered the n{)j)er lip on the left side, at the angle of the mouth, passed through that side of the tongue, one-half an inch from the tip, thence oblicpiely across, struck the right lower jaw at a point one inch in advance of its angle, passed downward and outward and emerged through the cheek, knocking out fouiteen or fifteen teeth, fracturing both jaws and cutting the tongue .almost off at the middle. The same ball, fracturing the clavicle in its middle third, lodged, and w.as removed by the patient. He received also a gunshot fracture of the bones of the foot. A jirofuse Innnorrhage followed, amounting to syncope, and the patient remained insensible for twenty-four hours. Being taken prisoner, he was removed to a ho.sj)ital on the field, and three days afterward waswnt to Pichmond, Virginia, where his wounds were dressed with cold water, but he received poor diet. He had colli<|Uative diarrha-a for two wei'ks. On .Inly 2.5th, 1862, he was paroled, and conveyed to Philadelphia, and, on July 29th, was admitt(!d into the. Broad and Cheriy Streets Hospital in a Very weak condition. The fragments of the jaw were exj)osed in the wound for some distance; the soft parts were sloughing, and rhe wound of the foot looked badly; that over the fractured clavicle had healed, with some union of the bone, the intier fragment overlapping. Lint, saturated with a solution of chlorate of j)otash, was applied to the wound of the cheek, and a flaxseed potdtice to the wound of the foot. Stimulants tind anodynes and liipiid diet wen- giv(‘n. Two large pit^ces of bone were removed. A few days after admission, the patient had another attack of diarrho-a, which continued two weeks, causing gn'at prostration. Kecovering from this, he impi-oved rai)!dly. On November 1st, 1862, the wound of the cheek had neaily healed. 360 WOUNDS AND INJUKIES OF TEE FACE. [Chap. II. leaving a deep scar. No callous was tlirown out ; the jaw was drawn toward the right side, giving rise to considerable deformity, and tile ])atipnt was unal>le to take solid food. A firm iniion of tlie clavicle had t.aken })lace. The wound of the foot had nearly healed. The patient was discharged the service on January 5th, lyC3, and pensioned. The case is reported hy Acting Assistant Surgeon John Neill. Case. — Piivate Aaron S , Co. G, 1st Maine Heavy Artillery, received a gunshot fracture of the inferior maxilla, in an engagement before Peteivshurg, Virginia, .Tune 18th, 18G4. He was at once taken to the hospital of the 3d division. Second Corps, where Dr. A. Garcelon, a volunteer surgeon, removed five fragments of the inferior maxilla, with a lateral incisor, canine and bicuspid teeth. Death resulted ou June 20th, 1804. The ])ath(dogical sj)ecimen, consisting of the ))ortions of bone removed, Was contributed to the Army Medical Museum by the operator, and is numbered .522 of the Surgical Section. Case. — Private Samuel W. S , Co. B, 1st New York Dragoons, aged 23 years, was wounded at Spottsylvania, May 8th, 1804, by a conoidal ball, which entered the back two inches below and a little to the right of the superior angles of the right scapula, and passing upward and forward through the neck and mouth, fractured the inferior maxilla. He received also a gunshot flesh wound of the left thigh. He was admitted into the general field hosjdtal of the Cavalry Corps at Fredericksburg, Virginia, on May 13th, 1804; thence he was transferred to Alexandria, Virginia; and, on May 24th, 1804, was admitted into the 2(1 division hospital. Ou May 27th, a copious secondary haemorrhage occurred from the mouth, which was arrested by the persuljdiate of ii'on, ])re.ssure, cold applications, and an elevated position. Extra diet was given. The patient died on June 4th, 1804. At the autopsy, it was found that the body of the inferior maxilla was fractured half way between the angle and the symphj’sis. The jugular vein just above the middle of the omo-hyoid muscle was found discolored, shriveled, closed, and, apj)arently, in a sloughy condition, and filled with coagulmu for two inches below the wound. The ha;morrhage was evidently from this vein. The .specimens are No. 2440, Sect I, A. M. M. (two fragments, being the right half of the inferior maxilla), and 2441, Sect. I, A. !M. IM. (a wet ]U'eparation of a portion of the light internal jugular vein). The specimens and history were contributed by Acting Assistant Surgeon Jonathan Cass. Ca.se. — Private .John W. S , Co. I, 82d Pennsylvania Volunteers, aged 21 years, was ■wounded at the battle of Cold Harbor, Virginia, June 3d, 1804, by a conoid.al musket ball, which entered ,at the left side of the nose, and, emerging opposite at ramus of inferior maxilla, fractured the superior maxilla at entrance and the inferior maxilla between condyle and ramus. He was conveyed to Washington, and, on June 10th, admitted to Emory Hospital, where, on the next day, the b.all and upper portion of the jaw were removed, and simple dressings applied to the wound. On June 21st, he was transferred to Haddington Ilosjiital, Philadeljdiia. ErysipGas, contiguous to the wound, supervened on July 0th, but disappeared under the aj)plication of iodine with stimulants internally. He was returned to duty on October 19th, 1804. The pathological specimen, consisting of one inch and a half of the right condyloid extremity of the inferior maxilla, including the articular sniface, was contributed to the Army Medical Museum by Surgeon N. K. Moseley, U. S. V., and is numbered 504 of the Surgical Section. The patient is not a pensioner. Case. — Private Johnson S , Co. D, 0th Alabama Infantry, aged 18 years, was wounded at Gettysburg, July 3d, 1803, hy a musket ball, which, entering about one inch from the chin on the left side, produced a compound fracture of the lower maxillary hone, and lodged. lie was admitted, on July 0th, to the hos]iital at Frederick, Maryland, where water dressings W’ci’e a])])lied to the wound. The location of the missile could not be det(*rmined. The patient’s general condition was good. On July 10th, sevei-.al small fi'agments of bone weie extracted. The patient, app.arently, did well until Se])tember 1st, the Wound of jaw having healed, when he complained of pain in the neck, which increased in severity. An abscess formed on the left side of the neck, discharging, when oj)ened, about four ounces of fmtid j)us. On September 18th, it was found that air passed through the o])ening made info this abscess. The ])atient complained of a feeling of numbness in the left side of the body, followed, on the 19th, by partial paralysis, which extended into the bladder. His ui’ine was drawn (jft' twice a diiy. Ou Seiitember 21st, he was placed upon a water bed. The ajiiiearance of the hack ji.art of the neck indicated some dis])lacement of the vertebra ; jn-essure uj)on that jiart of the neck produced a gurgling sound. Complete jniralysis had occurred hy September 23d, and the patient's strength was rajiidly failing. Milk punch was freely given, but a consider.able quantity of all the liquids taken by the mouth passed out through the fistulous opening. He continued to sink, and died on September 28th, 1803. At the autopsy, the fractured jaw was found to have only partially united. The hall had lodged in the fifth cervical vertebra, producing extensive comminution. The bone was very much necrosed, and the soft ])arts greatly disorg.anized. The su])puration extended to the spinal canal; there was red softening of the spinal cord. The fistulous op(‘ning extended into the ]iharynx. The pathological specimen is a wet preparation of the iiderior maxilla, showing a fracture of the body by a mu.sket ball, one-half inch to the left of the symphysis, partially united by ligament. The fracture runs obli(juely downward, forward, and inward, and one inch of the body of the bone, with the canine, bicuspid, and first molar teeth, had been comminuted and ])artia]ly removed. Sevei'al small fragments remain in situ. It was contributed to the Army Medical Museum, with a history of the case, by Assistant Surgeon R. F. Weir, U. S. A., and is nund)ered 3979 of the Surgical Section. Case. — Private Samuel T , Co. E, 88th Pennsylvania Volunteers, waswoimded at the Alexandria Prison, July 2Cth, 1804, by a musket hall. He died on the same day. At the autop.sjq the hall was found to have entered the right corner of the mouth and emerged just below the right ear, badly fracturing the right side of the lower jaw in several places, and rujjuring the iutei'ual maxillary artery. The hamiorrhage from the internal maxillary artery was siqiposed to have caused his death. The specimen is No. 33.50, Sect. 1, A. M. M., showing the right half of the inferior maxilla fractured, and a small portion of the ball attached. The specimen and history were contributed hy Surgeon Edwin B(mtley, U. S. V. Ca.se. — Corporal F. Augustus W , Co. K, 111th New York Volunteers, aged 22 years, was wounded at Gettysburg, Penusylvania, July 2d, 1803, by a conoidal hall, which fractured the right side of the inferior maxiHa. He was semt to the 'regimental hospital of the 111th New York Volunteers, and, on the same day, transferred to the general field hosjjital at Gettys- SlJCT. II.] GUNSHOT FRACTURES OF THE FACIAL BONES. 361 burg; thence lie was sent to Baltimore, and admitted into the Jarvis Hosiutal on July 15th, 18G3. Owing to the amount of swelling and the extreme tenderness of the mouth, the wound was not examined. The patient was able to take food in a li(|uid state until noon on July 2'2d, 18f)3, when he was found gasping for bi’eath, and died soon after. At the autopsy, it was found that the hall had entered about one inch to the right of the symjihysis, shattered the inferior maxilla, passed downward inside of the hyoid bone and lodged in the thyroid cartilage. The surrounding tissues were congested and infiltrated with blood. The ejiiglottis was much enlarged, and the larynx filled with coagulated blood. This man never had much h.x-morrhagi', and no large artery was found divided. The specimens are No. 1451 (a wet specimen of the maxilla), and No. 1440 (a wet, specimen of the larynx with the missile). Sect. I, A. M. M., and were contributed, with the history, by Acting Assistant Surgeon B. B. Miles. Case. — Private R. W , Co. F, 95th Pennsylvania Volunteers, aged 39 years, was wounded at Chancellorsville, Virginia, May 3d, 1803, by a conoidal ball, which entered the left side of the face at the infra-orbital foramen of the superior maxilla, and emerged between the ascending branch of the lower jaw and the traverse process of the atlas, half an inch external to the latter, in the left nuchal region, fracturing the malar bone below its infra-orbital edge and perforating the superior maxilla. He also received a gunshot fracture of the surgical neck of the right humerus. Being taken to Washington, he entered the Douglas Hospital on May 8th, 1863, suffering considerably from cough and im]ieded deglutition. On May 11th, there was paralysis of the facial nerves of the left side, the nerves presiding over deglutition, and the brachial nerves of the right side. The point of the tongue pointed toward the left side, on being stretched out. Several pieces of bone were removed fi'om the superior maxilla and its sinus. The wound of the face was plugged with charpie, Desault’s bandage was applied to the right arm, and stimulating diet was given. On May 19th, the fauces were red and inflamed. On Jlay 24th, the patient, while drinking a cuj) of tea, became suddenly suffocated and exj)ired. At the autopsy, it was found that ulceration of the oeso])hagus had taken place. The ball had barely escaped the latei’al process of the atlas. There was an effusion of blood into the muscles of the neck, causing compression, doubtless, on important nerves. No manifest cause for his sudden death was discovered. The pathological specimen is No. 1239, Sect. I, A. M. M., showing the left superior maxilla and a part of the malar bone fractured by a musket ball, which carried away the upper part of the body and the oi’bital process and the zygo- matic process of the malar broken off at its root. The pathological specimen of the fractured humerus is No. 1238, Sect. I, A. M. M. The specimens, with the history, were contributed by Assistant Surgeon W. Thomson, U. S. A. Case. — Private Daniel S. Wilkinson, Co. K, 7th Wisconsin Volunteers, aged 20 years, was wounded at the second battle of Bull Run, Virginia, August 30th, 1862, by a conoidal ball, which entered the right side of the upper lip, just below the ala of the nose, and emerged just behind the lower jaw, near the angle, fracturing the upper and lower jaw and carrying away all the teeth on the right side. He was admitted into the regimental hospital of the 7th Wisconsin Volunteers the same day, and afterwards transferred to New York City, and admitted into the Ladies’ Home Hospital on September 13th, 1862. Ordinary bandages and poultices were applied. On September 30th, 1882, a piece of bone, one-fourth of an inch in length, was removed. Several pieces of bone hav’e been discharged from the wound from time to time. On November 9th, 1862, the bone had com- pletely united ; when the mouth was closed the coaptation between the teeth was not entire. On January 14th, 1863, the wound had entirely healed, the patient’s health was good, and he was returned to duty, there being no difficulty with the jaw, excepting the overlapping of the fragments, and consequent shortening of the body of tlie jaw. The case is reported by Surgeon Alexander B. Mott, U. S. V. The patient is a pensioner, his disability being rated one-half and permanent. Case. — Sergeant David W. Scott, Co. I, 140th Pennsylvania Volunteers, was wounded at Gettysburg, July 3d, 1863, by a conoidal ball, which entered below the angle of the lower jaw, left side, passed under the tongue, and shattered the jaw on the right side. He was treated in field hospital until January 6th, 1864, when he was admitted to the hospital at Pittsburg, Pennsylvania. Simple dressings were applied. He was discharged from service on February 20th, 1864, on account of pseudo- arthrosis of both sides, preventing complete mastication. On February 22d, 1868, Pension Examiner D. Stanton reports that there is a false joint, owing to non-union of the bone. The patient is unable to masticate solid food. His disability is rated four-fifths and permanent. Case. — Private Dennis B , Co. I, 22d Massachusetts, was wounded at Fredericksburg, Virginia, Decend)er 13th, 1862, by a ball, which entered above and a little forwtird of the posterior fold of the left axilla, j)assed inward, uj)ward, and forward, and emerged just above the convexity of the left clavicle, which it shattered, again entered an inch nearer the neck, ])reserving nearly its original direction, finally emerging through the right cheek, breaking a few small |)icces from tlie middle of the lower edge of the jaw. He was conv(‘ycd to Washington, and, on December 18th, admitted to .Judiciary S(|uare Hospital. There was consider.able offensive di.scharge, particidarly from the first wound of exit. About December 30th, his mind hecame somewhat affected, and there was great and increasing tendency to sleep. On the night of .January 12th, 1883, he was attacked with violent pain in the left hypochondrium, which was partly relieved by the application of sinaj)isms. On .January 13th, two fragments of bone were removed with the forceps from the acromial portions of the clavicle ti’om which they had become partially detached. On January 14th, he went to sleep after eating heartily; his breathing was shorter than usual. Ui)on being spoken to he oj)eued his eyes, but closed them again ; his breathing became still shorter, and with longer intervals, for about five minutes, when he died, perfectly plied to the W'ound, and nourishing diet ordered. Several sjncula! of bone were removed on July 5th, and afterwards at various times. The motion of the jaw w'as much restricted, and could not be closed within one-fourth of an inch, nor opened more than one-half of an inch. Some of the smaller branches of the facial nerve were injured. He was discharged the service on August 12th, 1862. The case is reported by Acting Assist.ant Surgeon Willianf P. Moon. This man is a pensioner, his disability being rated three-fourths and permanent. Case. — Sergeant Franz Wolbe, Co. E, 31st New York Volunteers, aged 31 years, received, at the battle of West Point, IMay 7th, 1862, a gunshot wound. The missile entered the centre of the right cheek, carrying aw.ay, in its jiassagi', the superior maxilla and teeth, two-thirds of the hard palate, and about half of the tongue, and emerged near the angle of the mouth, on the left side, lacerating the soft parts to a considerable extent. He was, on May 14th, admitted into the general hospital, Alexandria, Virginia. The wounds were healing rapidly, and the patient doing well. He was discharged the service on August 11th, 1862. The case is rej)orted by Surgeon John E. Summers, U. S. A. Wolbe is a pensioner. The power of speech is partially destroyed. His disability is rated total. Case. — Sergeant Milo A. Dix, Co. C, 49th Ohio Volunteers, aged 23 years, was wounded at Nashville, Tennessee, December 15th, 1864, by a conoidal ball, which entered immediately beneath the septum of the nose, fractured both sui)erior maxillary bones at the symphysis, and emerged at the hack of the neck a little to the right of the median line, fracturing the transverse processes of the cervical vertebra;. He was treated in regimental hospital until-December 17th, whenhe was admitted to hospital No. 1, Nashville, and, on December 21st, transferred to Crittenden Hospital, Louisville, Kentucky. Simple dressings were apidied to the wounds. Death resulted on December 29th, 1864, from pyatmia. At the autop.sy, two or three metastatic abscesses were found in th(‘ base of the left lung. Portions of the lower lobe of the left lung were gangrenous, and there was a small quantity of sero-purulent matter in the left pleural cavity. Ca.se. — Corporal James Green, Co. C, 1st United States Colored Troo))s, aged 26 years, received a gunshot compound fracture of the lower jaw at Fair Oaks, Virginia, October 27th, 1864. He was admitted, on October 29th, 1864, to Balfour Hospital, Portsmouth, Virginia. Cold water was injected through the wound. Death residted on November 3d, 1864, from exhaustion. Case. — Private Joseph D. Parks, Co. A, 29th Connecticut Colored Volunteers, aged 30 years, was wounded in an engagement before Kichmond, Virginia, October27th, 1864, by a conoidal ball, which entered the left side of the face, midway between the angle and symphysis of the inferior maxillaiy, jtassed obliipiely inward and outward, abrading the tongue, and emerged af the aiigle of the inferior maxilla, right side, extensively fracturing the bone to within the capsule of left articulation, besides greatly comminuting the body of the jaw. He was at once taken to the hos|)ital of the Tenth Corps, being unable to articulate sufficiently distinct to be understood. On the same day, he was placed in a jjartiall}’ reclining position, and chloro- formed by Surgeon C. M. Ckark, 39tii Illinois Volunteers. An incision was then made, commencing at the lobe of the left ear, carried along the inferior border of the bone to the chin, and the soft parts dissected, leaving the jieriosteum. After removing all the loose fragments, the stumj) of the left ramus was grasped with the bone pliers and disarticulation accomplished with a few strokes of the knife. A similar incision was then made on the right side to connect with the other, severing the geniohyo- glossus and geniohyoid muscles, and the tongue retracted so as to fill the pharynx. The tongue was then drawn forward and retained in that jiosition by means of a silk cord j)assed through it and •fastened externally. The bone was then dissected the same as on the oi)posite side, and removed to within a short di.stance of the sigmoid notch, where it was found to be sound, and was severed at the upi)er third of ramus by a chain saw ; the ^vound was brought together with silk sutures. Cold water dressings and compress, with paste-board support, were apjilied, and nourishing diet administered through a tube. The operation occupied one and a half hours time. Very little blood was lost. The only artery ligated was the facial ; the others were twisted. The patient was at no time unconscious, and bore the operation with great fortitude. Death resulted on November 6th, 1864, from exhaustion. The case is reported by the operator. Ca.se. — Private Isaac Smith, Co. H, 39th Illinois Volunteers, aged 19 years, was wounded at Deep Bottom, Virginia, August IGth, 1864, by a conoidal ball, which caused a comminuted fracture of the right inferior maxilla. He was admitted to the hos]>ital at Fort Monroe, Virginia, August 18th, 1864, suffering from traumatic irritation and insomnia. On August 2t)th, Acting Assistant Surgeon S. J. Holley anffisthetised the patient, and excised the right ramus anil two-thirds of the body of the lower jaw. The hajmorrhage was slight ; one ligature was ajiplied. I’atient reacted jironijitly. On October 8th, he was transferred to Grant Hos[)ital, Willett's Point, New York, and transferred to the Veteran Beserve Corps on May 4th, 1865. Pension Examiner C. IJ. Parke reports, February 27th, 1869, that “a small fistulous opening remains, from necrosed bone; serous discharge. Stooping causes dizziness. He is subject to slight indigestion, caused by inability to masticate his food thoroughly.” Sect. II.] GUNSHOT FKACTURES OF THE FACIAL HONES. 3G3 Ca.se. — Private Saninel H , Co. G, SCrth Now York Volnntoors, aged 1!2 yoars, was woiiii(lc(l at Gottyslmrg, I’omi- sylvania, July Jd, 18o3, by a fragment of shell, •which lacerated the cheek severely and fractured the left inferior maxilla, the lower portion of the body of the bone being severely comminntetl. The alveoli were but slightly injured. Ho was at once taken to the field hospital, where Assistant Surgeon J. Theodore Calhoun, U. S. A., administered chloroform, and removed, piece bv piece, the left half of the body of the inferior maxilla, between tbe central incisors anteriorly and the last two molar.s behind, following the line of fracture which involved the alveolar arch at those ])oints only. The bone, whicb was broken acro.ss transversely, was rendered quite smooth by the bone forceps at or near the angle (jf the jaw. A Hey’s saw was used, the soft jiarts being held out of the way by a spatula. Uuring the operation, the tongue was carefully kept in situ, by a ligature ji.assed through its lip and held hy an assistant. After carefully securing all the bleeding vessels, and removing the bui-nt or destroyed tissue, the excessively ragged wound was brought together in accurate ai'position by the introduction of silver i)ius with a wire figure-of-8 suture. On July IGth, ho was transferred to McKim’s Mansion Hospital, Haltimore, and on November 2Ist, 188:5, to Patterson Park Hospital, where he was reported a.s convalescent. In a letter to this office,^ dated May 28th, 1886, the operator states that “the cicatri.x is nearly four inches long, and is almost hidden by his beard. His appearance is quite good. He lives mainly upon food of a semi-solid consistence, and conqilains. of indigestion to some extent." The pathological sj>ecimen, consisting of the excised portion of boive, was forwarded to the Army Medical Museum by the operator, and is numbered 1532 of the Surgical Section. Not a pensioner. Case. — Private Daniel Beckhorn, Co. E, 8th New York Heavy Artillery, aged 18 3 'ears, was wounded at Cold IIarl)or, Virginia, June 3d, 1864, b_v a conoidal musket ball, which entered the mouth, fractured the lower jaw, and emerging at its right angle, passed through the right shoulder, injuring the head of the humerus. He was convej’ed to Washington, and, on June 8th, admitted to the Emorj' Hospital. Cold water dressings were applied, and, on .lime 11th, he was transferred to Patterson Park Hospital, B.altimore. On June 13th, ten fragments of bone were removed from the jaw, and, on Julv 1st, three ])ieces more. The di’cssing consisted of oakum, wet with baker’s yeast. On July 20th, the remaining loose jiiece of jaw, containing four teeth, commenced to unite. Fragments of hone were, at various times, removed from the wound of the shoulder, which progi-essed favorabh', and, on September 11th, the patient could move the shoulder in all directions, but the jiower of abduction was somewhat imp.aired. On September 12th, he was furloughed; on October 23d, admitted to the lilower Hospital, I’hiladelphia, whence he was returned to dut^v on April 15th, 1835. The pathologic.al specimen, consisting of six fragments of bone from the inferior maxilla, was contributed to the Army Medical Museum, by Acting Assistant Surgeon J. W. Faj', and is numbered 3467 of the Surgical Section. The patient is not a pensioner. Ca.se. — Private John Boon, Co. C, 8th Ohio Volunteer.s, was wounded at Chancellorsville, Virgini.a, Ma_v 3d, 1863, \>y a ball from a case-shot, which entered one inch below the right angle of the mouth, and lodged at a point one inch in front of the angle of the jaw. He was treated in field hosjntal until May 9th, when he was admitted to the Carver Hospital, Washington. There was a hard and painful swelling over the lower jaw, near its angle. There was no wound within the mouth. Fracture of the jaw could be detected. An .abscess formed below the jaw, which was opened on Mu}' 18th, and again on the 20th, allowing the escape of considerable jms. On Maj' 22d, a bullet was discovered within the wound, which was removed with forceps by Acting Assistant Surgeon B. F. Craig. Poultices were applied over the jaw and wound, and on ,Iune 2'.5d, the jiatient was transferred to the McClellan Hospital, Philadelphia, thence on October 24th, to Camp Dennison, Ohio, when- he was treated for syphilis nntil November IGth, 1833, when he was returned to duty. The .specimen, showing a .spherical leaden ball somewhat grooved at one portion, with a long fragment of bone imbedded, was contributed to the Army Medical IMuseum by the ojierator, and is numbered 809 of the Surgical Section. He is not a pensioner. Case. — Private Albert Bryant, Co. H, 19th Indiana Volunteers, was wounded at Antietam, Maiwland, Septefnber 17th, 1862, by a conoidal musket ball, which entered at the right tingle of the mouth, cut its way through the upper surface of the tongue, and fractured the lower jaw at its angle. He was treated in field hosjiital until Sejitember 29th, when he was admitted to the 1st division hospital, Alexandria, Virginia. There was ])ersistent swelling and inflammation, with incessant suppuration inside the mouth and at the angle of the jaw. The jaws became fixed, three-fifths- of an inch apart. On October 30th a large ])iece of loose bone, triangular in .shape and an inch in altitude, consisting of the angle of the jaw, was extracted by Surgeon .John E. Simimers, U. S. A., and the presence of the ball detected. On November 4th, the jiatient w.as chloroformed, and search being made for the ball, it was at length discovered firmly imbedded outside and beyond the angle of the jaw, whence it was extracted with very great difficulty. The ]iatienl recovered, and was returned to duty on Noyember 18th, 1HG2. The missile, a conoidal ball, with a longitudinal h.alf, obliipiely and roughh- torn off, and the iqqiosite side of the cup rolled up outwardly- uiion itself, was contributed to the Army Medical Museum h^- Acting Assistant .Surgeon George F. French, and is numbered 29/G of the Surgical Section. Biyant is not a pensioner. C.VSE. — Priyate Peter Both, Co. E, 4th United .States Artilleiy, was wounded at Frederick.slmrg, Virginia, December 13th, 1832, by a musket ball, which lodged in the left superior maxilla, after haying shattered the malar bone. He was admitted to the Cai-yer Hospital, Washington, on December 21st, and on January 8th, 1833, transferred to Patterson Park Hospital, Baltimore, where, on January 11th, Acting Assistant Surgeon ’Theodore Artaud extracted the ball and fragmi-nts of bone. After the extraction of the ball, the prohe could communicate freely- with the antrum of Highmore. 'The wound he.ilcd with some depression. 'The patient was returned to duf^y iu June, 18G3. 'The j.athological siiecimen, a yery greatly battered leaden bullet, was contributed to the Army Medical Museum by the operator, and is numbered 4.554 of the Surgical Section. Both is not a pensioner. Ca.se. — Priyate Daniel C. Ulfelman, Co. B, 198th Pennsylyania Volunteers, aged 19 years, was wounded at South Side Bailroad, Virginia, April l.st, 1835, ly a conoidal ball, which entered one ijuarter of an inch to the left of the s^'mphv'sis, and fracturing the jaw badly, emerged under the chin, reentering the neck just beside the trachea, and lodged, as was supl.osed, in the ceryical vertebra;. He was at once admitted to the held hospital of the 1st division, I’iflh Corps, where the teeth and some 364 WOUNDS AND INJUItlES OF THE FACE [Chap. II. pieces of bone were removed. On A))ril 4tb, 1805, lie wns sent to tlie depot field lio.spital of tlie Fiftli Corps, tlience tran.sferred to Wasliington, and, on April 7tli, admitted into the Finley Hospital. On April 14tb, .two pieces from the symidiysis of the inferior maxilla were removed by Surgeon G. L. I’ancoast, U. «S. V. Splints and simple dressings were tipplied. Special diet ■was given. On May 19tli, be was transferred to the Mower Hospital at Pbiladeljihia, where he was mustered out of service on June 5th, 1805, in accordance with general order from the War Department, dated May' 3d, 1805. The specimen is No. 4288, Sect. I, A. M. M. (two small fragments from the symphysis of the inferior maxilla, one inch long by one-fourth of an inch wide), and was contributed, with the history, by the oyierator. Uffelman is not a pensioner. Case. — Private .Tohn Schultz, Co. H, 7th Wisconsin Volunteers, aged 28 years, was wounded at Gettysburg, Pennsyl- vania, July 1st, 1803, by' a conoidal ball, which entered at the right superior maxilla, passed backward and downward, and lodged under the integuments behnv the mastoid process of the te\nporal bone. He was admitted, on the next day, to tbe Seminary' Hospital at Gettysburg, where the ball was removed, and, on July 12th, he was transferred to Turner’s Lane Hos])ital, Philadelidiia, whence he was transferred to the Veteran Reserve Corps on November 4th, 1863. The missile, showing the apex flattened njxm the body, and tbe base laterally compressed, was contributed to the Army' Medical Museum by Acting Assistant Sur- geon David Burjiee, and is numbered 4533 of the Surgical Section. Schultz is not a pensioner. Case. — Corporal James P. Stewart, Imlependent Battery E, Pennsylvania Artillery, aged 25 years, was wounded at Brown’s Ferry’, Tennessee, October 28th, 1803, by' a musket ball, which entered the right cheek just altove the angle of the lower jaw, pas.sed horizontally through and emerged from the centre of the left cheek, fracturing the inferior maxilla upon the right side, ojiening the maxillary’ antrum, fracturing the palatine arch and the body' of the superior maxilla on’ the right side, lacerating the .soft palate and nearly severing the tongue. He was admitted, on the next day, to hospital No. 2, Chattanooga, Tennessee. Deglutition and s|)eech W’ere entirely suspended. Simple dressings w'ere ai)plied to the wound, and beef soup and milk given twice a day by means of a stomach tube passed into tbe pharvnx. Under this treatment the patient commenced to improve, and by November 16th, the external wounds had nearly healed ; he was able to speak indistinctly and swallow a little. No further information can be obtained until April 11th, 1864, when he was admitted to the hospital at I’ittsburg, Pennsylvaniii, whence he was discharged from service on May 3d, 1864. The powers of deglutition, mastication, and articulation are seriously injured. He is a pensioner. Case. — Private Henry A. Preston, 4th Rhode Island Battery', was wounded at Antietam, Maryland, September 17th, 1862, by a rou7id ball, which entered at the roots of the molar teeth of right side, upper jaw, and passed out at the angle of the left inferior maxilla, comminuting the bone to tbe extent of two inches. He was convey’ed to Baltimore, and, on September 21st, admitted to the Newton University Hospital. On September 23d, Surgeon C. W. Join's, U. S. V., removed the fragments of bone by dilating the opening made by' the exit of the ball. The w'ounds bealed rapidly w’ith but slight deformity, and the jiatient was returned to duty on November 13th, 1862. The pathological specimen, consisting of two fragments and the crowns of two molar teeth from the left side of the inferior maxilla, was contributed to the Army Medical J.Iuseum by the operator, and is numbered 463 of the Surgical Section. He is not a pensioner. Ca.se. — Corporal H. H. Pryor, Co. H, 11th Pennsylvania Volunteers, aged 29 years, was wounded at Antietam, Septem- ber 17th, 1862, by a conoidal ball, which entered the left side of the nose, just above the low'er edge of the nasal bone, jiassed obli(juely’ across tbrough the antrum on the right side, and emerged just below the malar process, causing difficulty of respiration and partial loss of sight of right eye. Free hsemorrhage follow'ed for about twenty minutes after he received the injury, when it ceased, and did not return. He was admitted into the Broad and Cherry' Streets Hos])ital, Philadel])hia, on December 11th, 1862. He stated that one or two small pieces of bone w’ere discharged from the w’ound of entrance; that the only' treatment he received was the application of a simple dressing to the w’ound, and that at no time did the wound give him much trouble. On his admission into this hospital the wounds had entirely healed w ith very slight deformity. He was discharged the service January 9th, 1863. The case is reported by Surgeon John Neill, U. S. V. Pry’or is a pensioner. Ca.se. — Sergeant Cy’i'us C. Holmes, Co. G, 18th Massachusetts Volunteers, w’as wounded at Bull Run, Virginia, August 29th, 1862, by a conoidal ball, which entered at the symphysis of the lower jaw on the median line, passed downward and backward, and emerged about two inches from the jilace of entrance, knocking out tw’o of the canine teeth, two bicuspids, and the hrst molar of the right lower jaw’. He was conveyed to Alexandria, Virginia, and admitted into the 3d division hosjiital on Se])tember 1st, 1862. Loose fragments of the jaw’ w’ere removed. He w as discharged the service on October 27th, 1862, with rigidity and loss of power of the muscles of the jaw', caries of the boue, and listulous ulceration of the glands. The case is rejiorted by’ Surgeon Edwin Bentley, U. S. V. Hidmes is a pensioner. Case. — Corporal Asa W. Taylor, Co. D, 83d New York, aged 32 years, was wounded at Antietam, September 17th, 1862, by a musket ball, w'hich entered at the posterior edge of the right sterno-cleido mastoid muscle, just below tbe occiput, and emerged just below' tbe left nostril, fracturing the lower jaw a little anterior to the ramus of the right side, destroying several teeth, jiassing through the hard palate, and knocking out tw’o of the front teeth. He w'as sent to Frederick, Mary’hmd, and, on Sejitember 24th, 1862, admitted into Hospital No. 1, and, on Sejitember 27th, w'as sent to the Si.xteenth and Filbert Streets Hospital at Philadeljihia. On his admission, the wounds were sujijuirating moderately’. There w’as no fever, or consti- tutional irritation. The voice, at first lost, w’as partially' regained. A bandage was apjilied to the fractured jaw, and cerate dressings to the W'ounds; soft and li(iuid diet was ordered. He was discharged the service on December 30th, 1862, doing well in all respects. 'I'he case is rejiorted by Acting Assistant Surgeon A. D. Hall. Taylor is not a pensioner. Case. — Private Samuel Yoder, Co. D, 3d Pennsylvania Reserves, aged 21 years, was wounded at. Bull Run, Virginia, August 29tb, 1862, by a conoidal ball, which entered the right cheek, at the anterior edge of the masseter muscle and emerged Skct. II.] GUNSHOT FRACTUHKS OF TIIK FACIAL HQNES. 365 at tlie chin, close to the syuipliysis, carrying away two inches of the body of the right inferior inaxilla, and extensively hican'ating the soft parts in the floor of the mouth. He w.as sent to Alexandria, Virginia, and admitted into the 3d division hospital on Sei)tember 1st, 18G2. Fragments of hone were removed from time to time. Slight infl.ammatory action ensued. He was discharged the service on Uecemher 1st, 1862, with i)artial anchylosis of the jaw. The case is reported hy Surgeon Edwin Bentley, U. S. V. Yoder is a pensioner, his disability being rated total and i)erm.ment. Case. — Private G. W. Gibson, Co. C, 4th Vennont Volunteers, was wounded during the seven days’ battles in June, 1862, hv a colloidal hall, which entered the middle third of the inferior maxilla, left side, passed downward and backward, and made its exit at a ])oint over the spine of the left scainda. He was admitted into the McKim’s Mansion llosjiital, Baltimore, July 2.')th, 1862. Flight small fragments of the inferior maxilla were removed from beneath the upjier third of the sterno-cleiilo- mastoid muscle. On September 19th, 1862, the patient was transferred to the West's Buildings Hospital, Baltimore, where he Avas discharged the .service on October 9th, 1862, for phthisis. The specimen is No. 413, Sect. II, A. M. M., and Avas contributed, Avith the history, by Surgeon L. Quick, U. S. V. He is a pensioner ; his disability is rated one-half. Case. — Private Ellis ITllom, Co. H, 110th Ohio Volunteers, aged 31 years, Avas Avounded at Monocacy, Maryland, July 9th, 1864, by a conoidal musket ball, Avhich entered one inch before the prominence of the left malar hone, j)assed directly through, and escaped one inch heloAV the ear, fracturing the superior maxillary hone. Fie Avas treated in field hospital until August 16th, Avhen he Avas sent to the Chester Hospital, Pennsylvania. On admission, his general health aauis poor, and he suft’ered severely from pain in the head. Both Avounds Avere discharging healthy pus ; pus Avas also discharged from the external auditory meatus. The hearing of the left ear Avas entirely gone. There Avas jiaralysis of the right arm immediatidy after the inJiUT, Avhich still continued. Several pieces of hone Avere removed, and stimulants and nutritious diet administered. By August 26th, the discharge from the Avound, pain in the head, and {)aralysis of the arm had dimini.shed, and he had some janver over the hand and fingers. He Avas transferred, on 8e])tcml)er 23d, to Turner’s Lane Hospital ; on October 1st, to F’ilbert Street Hospital, and, on Jilarch 6th, 1865, Avas returned to Turner’s Lane Hospital, Avhere galvanism Avas apjilied daily. On !May 9th, 1865, he Avas discharged from service. He is a pensioner. The sight of the left eye is entirely gone, from paralysis of the nerves. His disability is rated total and permanent. Case. — Captain .John Algoe, Co. A, 10th Micliigan Volunteers, aged 31 years, Avas AVOunded at .Jonesboro’, Georgia, September 1st, 1834, by a conoidal ball, Avhich passed through the loAver edge of the r.amus of the inferior maxilla, comminuting the bone and tearing the parts extensively. The tongue lay upon the sternum. He Avas taken to the hos])ital of the 2d division, F''ourteenth Corp.s, Avhere Surgeon EdAvard BatAvell, 14th Michigan Volunteers, removed the fractured ])ortions of hone, saAved off the ends of the angles, and brought the edges of the AVOund together hy interruirted sutures. At the end of three Aveeks all had united, except at the loAver extremity of the right angle, Avhere the loss of substance had formed a fistulous opening. The surrounding tissues Avere loosened, .an incision about one inch and a half long Avas made through the opening, .and the edges th.al had been pared brought together and retained in position Avith pins and tAvisted suture. At the end of six Aveeks, the AVounds Avere perfectly healed, and his general health Avas not at all impaired. A fibrous tissue appe.ared to take the place of the bone, and afforded considerable resistance to the upper teeth in m.astication ; but the tongue seemed to be the chief agent made use of by nature to compensate for the loss of the loAver JaAV. On October 25th, 1864, he Avas sent to the Officers’ Hospital, Lookout Mountain, Tennessee, and discharged from service on March 8th, 1865. He is a pensioner, his disability being rated total and permanent. Case. — Private .John IT. Spear, Co. H, 29th Massachusetts Volunteers, aged 32 years, Avas Avounded before Petei'sburg, Virginia, .July 29th, 1864, hy a conoidal b.all, Avhich perforated and broke the nasal process of the upper j.aAV on the left side, passed obli(piely doAA'iiAvard, and emerged near the right angle of the mouth, fracturing, in its course, the superior maxilla and hard pal.ate, and base of the loAver JaAV. He Avas t.aken to the hospital of the 1st division. Ninth Corp.s, Avhere the front of the superior maxilla and a portion of the hard palate Avere excised, and simple dressings apjdied to the AVound. On August 1st, Jie Avas admitted to IlareAvood Hosi)ital, Washington, Avhence, on October 22d, 1834, he Avas transferred to the Veteran Reserve Corps. In February, 183.5, he Avas furnished Avith an artificial juAV, at Avhich time the Avound had healed. He is a pensioner. The fissure through the roof of the mouth causes great inconvenience in deglutition ; fluids are throAvn through the nose. His disability is rated total and permanent. Case. — Corporal Alfred W. Smith, Co. D, 9th Maine Volunteer.s, .aged 29 years, Avas Avounded at F''.air Oaks, Vii’ginia, October 27th, 1864, bj' a conoidal ball, Avhich fractured the inferior maxilla. He Avas taken to the hospital of the Tenth Cori)s, Avhere the fractured ])ortion of the bone Avas removed and simjile dressings apj)lied. On October 31st, he Avas sent to the hosjiital at F’ort Jlonror, Avhence he Avas furloughed on December 26th, 1864. He Avas discharged from service on October 29tli, 1865. He is not a pensioner. Case. — Sergeant Elias Gabriel, Co. B, 24th loAva Volunteer.s, aged 24 ye.ars, Avas Avounded at Cedar Creek, Virginia, October 19th, 1864, by a conoidal ball, Avliich entered the right side of the face, close to the ala of the nose, ])assed outAvard. and emerged on a line.Avith, and one inch behind, tin* lobe of the left ear. He Avas taken to tlu! hospital of the Nimdeenth Coius, Avhere simi)le dressings AA'ere .applied to the AVound. On October 25th,lie Avas transferred to the hosi)ital at York, Pennsylvaiua. There AA’as a discharge of serous fluid from the left ear. the he.aring of Avhich Avas entirely d(!stroyed. He Avas unable to close the left earn, but there AV.as some motion in the lids. The Avound of exit had nearly clo.sed. By November 2d, both nostrils Avere discharging, and there Avas paralysis of the mu.scles of tin; left cheek. He Avas transferred to I)aveni>ort, Iowa, on Decemher 15th, 1864, and discharged from service on January .5th, 18,35. On October 29th, I8(i9, Pension Examiner W. Wakefield reports that the injured hones are in a diseased conditioTi, and exfoliating, causing pain, discharge from the nose, deafness of the right ear, and p.aralysisof the right side of the face. 366 WOUNDS AND INJURIES OE THE FACE [Chap. II, Case. — I’rivatu William JIcDaiiiels, Co. F, 5th United States Colored Troops, aged 22 years, was wounded at Deep Bottom, Virginia, September 29th, 18'J4, by a musket ball, which entered anterior to and below the right malar bone, and ranging backward, downward, and obli(piely to the left side of the face, emerged over the left angls of the inferior maxilla. He was treated in field hosj)ital until October Gth, 18G4, when he was admitted to the Balfour IIosj)ital, I'ortsmouth, Virginia. On Octobei’ 15th, a fragment of bone was removed. Simple dressings were applied to the wound, and stimulants given internally. He improved slowly and steadily, and, on June 27th, 1805, was transferred to Fort Monroe, whence he was mustered out of service on October 14th, 1865. He is a pensioner. The wound healed, leaving (juite a large opening into the nares between the roof of the mouth and the soft" palate. There is partial anchylosis of the lower jaw. His disability is rated onedialf and permanent. Ca.se. — Corporal Thomas H. Matthews, Co. I, 198th Pennsylvania Volunteers, aged 26 years, was wounded before Petersburg, Virginia, March 29th, 1865, by a conoidal ball, which entered below the left car, and emerged below the left eye, fracturing, in its course, the condyle and coronoid ))rocess of the inferior maxilla and zygomatic process of temporal and malar bones. He was at once taken to the hospital of the 1st division. Fifth Corps, and on Ajuil 2d, sent to Harewood Hosjiital, Washington. When admitted, the left side of the head and face was very much inflamed, with slight ery.sipelas in right eye and face; he suffered also from the effects of the shock of the injury and transportation from Petersburg. On Aj)ril 14th, the zygomatic j)rocess of the temporal and fragments of the malar bone were removed. Bj' May 19th, the patient had fully recovered, with the e.xception of a slight anchylosis. He was discharged from service on May 29th, 1865. He is a pensioner. Pension Examiner H. S. Woodruff rejiorts that he is almost totally blind in the left eye, and deaf in the left ear. He is affected with fainting fits, on stooping. His disability is rated total and permanent. Case. — Private Joshua Simmons, Co. G, 74th Ohio Volunteers, aged 32 years, was wounded at Jonesboro’, Georgia, September 1st, 1834, by a round ball, which fr.actured the infei'ior maxilla, right side. He was sent to the hospital of the 1st division. Fourteenth Corps, where simple dressings were ap])lied to the wound. On October 27th, he was transferred to Hospital No. 2, Nashville, Tennessee, whence he was discharged from service on February 16th, 1863, on account of anchylosis of the jaw. He is a pensioner. Case. — Private William Higginson, Co. B, 131st New York Volunteers, aged 35 years, was wounded at Winchestej’, Virginia, by a musket ball, which caused a compound comminuted fracture of the left inferior maxilla, and lodged in the spinous ])rocess of the left scapula. He was taken to the field hosjiital of the Nineteenth Corps, where the ball was removed, and 8im])le dressings ai)plied to the wound. On October 12tli, he was transferred to the hosjiital at Frederick, Maryland. Fragments' of bone were removed on Novendier 4th. He was furloughed on March 13th, 1865, and, on Ajiril 5th, was admitted to Grant Ilo.sjiital, Willett’s Point, New York. On June 2d, he was transferred to De Caniji Hosjiital, whence he was discharged from service on June 16th, 1865, on account of loss of half of lower jaw. He is a jiensiouer. Pension Examiner G. S. Gale rejiorts that the remaining jwrtiiin of the lower jaw does not match the ujijier, and mastication is quite imperfect. Case. — Private Henry Morgan, Co. D, 77th New York Volunteers, aged 24 years, was wounded before Petersburg, Virginia, Ajiril 2d, 1865, by a conoidal ball, which entered at the left sujierior maxillary bone, facial surface, jjassed inward and downward into the mouth, destroying all the ujiper teeth on the left side. He was admitted, on the same day, to the hosjiital of the 2d divi.sion, Sixth Corjis ; simjile dressings were ajijilied to the wound. On Ajiril 12th, he was transferred to Harewood Hosjiital, Washington. When admitted, the right side of the head and face were very much iuHamed, ('lysijielas closing both eyes, which disajijieared under ajijirojiriate treatment, and, on May 1st, the jiatient was doing well. He was discharged from service on June 8th, 1835. He is a jiensioner. Case. — Private Ferdinand Lauersdorf, Co. D, 6tli AVisconsin Volunteers, aged 28 years, was wounded in an engagement on the South Side Railroad, near I’etershurg, A^irginia, March 31st, 1865, by a fragment of shell, which struck the body of the lo\7erjaw, and tore away the entire anterior jiortion of the bone. He was 'conveyed to the hosjiital of the 3d division of the Fifth Corjis, and, on Ajiril Gth, sent to Camjiliell Hosjiital, AVashington, whence he was discharged from service on July 14th, 1865, on which date a jihotograjih was taken at the Army Medical Museum. The fractured extremities of the jaw had united, and the wound had neaily healed. The movements of the jaw were very limited, but deglutition was but slightly interfered with. He is a jiensioner. Ca.se. — Private John Keil, Co. K, 102d Pennsylvania A''olunteers, aged 25 years, was wounded at the AA'ilderness, Virginia, May 5th, 1864, by a conoidal ball, which entered at the inner canthus of the left eye, passed through under the nose, and lodged in the right antrum of Highmore, jienetrating the right sujierior maxilla, and knocking out the second molar tooth on the right side. He was conveyed to AAhishington, and admitted into the Stanton Hosjiital on May 11th, 1864. On May 23d, the wound of entrance had nearly healed; there w'as a jiurulent discharge from the right nostril, and a fissure in the anterior pai-t of the supei'ior maxilla, the length of which could not be satisfactorily ascertained. A jirobe was readily passed into the antrum. Assistant Surgeon George A. Mursick, U. S. V., made an incision from the angle of the mouth to the lower edge of the malar bone, turned uji the fiaji of the cheek, ajiplied a large trejihine over the antrum, removed a button of bone, and extracted the ball, which rvas found lying loose in the antrum. The jiatient’s constitutional condition was good. On May 24th, he had some fever and swelling of the cheek. On May 2.3th, the swelling of the firce had increased and was erysipelatous in ch.aracter. f)n May 27th, the swelling having nearly subsided, the sutures were removed. The lower half of the incision had united by first intention ; the remainder was sujijiurating ; the discharge from the nostril had diminished, and the jiatient was doing well. On August 1st, the wound had not healed ; there was an ojiening over where the bone was trejihined. Some small jiieces of bone were discharged, both from the wound of ojieration and the nostril. The jiatient was able to chew his food well. On Sejitember 3d. 1864, his term of enlistment having exjiired, he was discharged the service. The wound of Motl H J-urg. Hitsl . of tlie War of tlie Kebellion, Part I. Vol.II. Op j)aOe 007 I'l. A.S|)ierovisional callus thrown out had been partly absorbed, and the inflammatory deposits about the jaw nearly removed. All the contraction of the soft jiarts that could ensue had taken jdace, and the saliva continually flowed from the mouth, obliging him to wear a pad and bandage over it. On January 23d, 186.5, Surgeon H. Culbertson, U. S. V., performed the following operation : The flaps having been marked out, a curvilinear incision was made from angle to angle of the mouth, the convexity downwards, leaving a portion of the remnants of the lower lip one-foui-th of an inch wide, adherent to the jaw, which was turned down so as to prevent the new lip from contracting adhesions to the jaw in fi’ont. Quadrilateral flaps were then raised from below the jaw, and the mucous membrane detached and stretched to the margin of the new lip, which extended towards the middle line of the lip, about one inch fi'om either angle. The two flaps were approximated in the middle line by four pins and figure-8 ligatures. Triangular spaces at base of jaw were dressed with dry lint. As the angles of the mouth were too rounded, a small V-shaped portion was taken out of each, and the edges of each approximated by a needle and thread. There was no stress on the flai)s, and no vessels divided that rccpiired taking up. Immediately after the o])eration, three-fourths of a grain of morphia was given, and 370 AVOUNDS AND INJUEIES OF THE FACE [Chap. II, tho patient enjoined not to move liis face or lip. On January 24tb, tlie flaps having taken well, he was ordered to lay on his side, that the discharges might readily flow off from the mouth, and the attendants were instructed to remove gently and frequently the mpisture from and about the flaps. He was allowed chicken broth, and cold water and lint dressings were aiiplied. This man was discharged on May 13th, 1865, and pensioned, his disability being rated total and permanent. The case is reported by the oj)erator. Cask. — Corporal Henry Gibbs, Co. K, 67th Ohio Volunteers, was wounded at the battle of Winchester, Virginia, March 23d, 1862, by a musket ball, which entered at one angle of the jaw, passed under the tongue, and emerged at the other, fracturing the lower jaw at both angles and in its body. He was conveyed to the Union Hospital at AVinchester, Virginia, and, on March 27th, Surgeon S. FA Forbes, 67th Ohio Volunteers, made an incision from thb angle of the mouth on the right side to the orifice of exit, and removed the whole of the lower jaw. A plastic operation was then performed, pins put in, and in four weeks the patient had entirely recovered without any a])parent external deformity. He was admitted to the hospital at Camp Chase, Ohio, July 2d, 1862, and discharged from service on July 4th, 1862. He is not on the Pension List. Case. — Private Peter Jordan, Co. E, 2d Connecticut Heavy Artillery, was wounded at Cold Harbor, Virginia, by a fragment of shell, which carried away the lower incisor teeth, with a large portion of the anterior part of the lower jaw, and destroyed the whole under lip. He also received a severe wound of the left hand. He was treated in the hospitals at Black- well’s Island, New York, and New Haven, Connecticut, and, on October 16th, he was admitted into the Eeadville Hospital, Massachusetts. On November 28th, 1864, Acting Assistant Surgeon Francis C. Ropes dissected up the soft parts from the jaw, and retained them as high as possible with bandages. Dressings of chloride of soda were applied. There was a slight sloughy appearance for a few days. Healthy granulations set in, and the wound healed, with some improvement in appearance and comfort of patient. He was discharged on January 16th, 1865. The case is reported by the operator. On January 24th, 1870, Pension Examiner J. AY. Toward reports that the saliva constantly dribbles from the patient’s mouth. The mouth presents a shocking deformity, which, in a great measure, excludes him from society. He has had three operations performed on his lip. Case. — I’rivate Donald Gray, Co. E, 38th New York A’^olunteers, aged 38 years, was wounded at F’redericksburg, Virginia, December 13th, 1862, by a round mmsket ball, which entered just under the right eye, fractured the upper maxilla, not materially separating the fi agments, and lodged. On admission to the Satterlee Hospital, Philadelphia, December 23d, 1862, the cheek was greatly swollen. On January 3d, 1883, the swelling having considerably subsided, the ball was removed from behind the masseter muscle by an incision. Numerous fragments of bone were found firmly imbedded in the ball, and an abscess, Avhich had formed in its place of lodgemeiit, discharged freely, and was kept open by the introduction of a tent. On the 22d, the wound had entirely healed. Gray had been wounded once, in lhe Crimea, in the head, and four times during the late war. One of these wounds had disfigured his nose. The right side was slit, at the junction of the ala and septum, for about Inalf an inch, and on the loft, a /^-shaped portion was lost at the same place. On February 11th, 1863, Acting Assistant Surgeon AV. AA^. Keen, jr., operated on the right side, simply paring the edges, and approximating by five sutures. On the left side, the mucous membrane and fascia of the ala and septum were everted, their edges pared and approximated by sutures. A plug was also placed in this' side to prevent inversion, and cold water dressings were apjilied. The edges united perfectly, except a portion of the elevated flaps, which, after a second opening, March 1st, 1833, united firmly, and completely filled up the gap. This man was discharged on March 14th, 1833, on account of inability to eat any hard food. He applied for a pension, but his claim was rejected, there being no disability. Case. — Citizen Henry Kennedy, aged 19 years, was admitted to the General Hospital at Little Rock, Arkansas, on August 23d, 1864, with loss of the inferior lip from mercurial gangrene, the superior margin of the cicatrix being firmly adherent to the periosteum covering the inferior maxilla. His constitutional condition was very good. On August 24th, Surgeon FI A. Clark, U. S. V., performed a rhinoplastic operation by dissecting the cicatrix and paring the edges, and drawing up the tissues of the skin and retaining them in conjunction with the remaining portions of the lower lip. Simple dressings were applied. The patient was retnrned to duty on September 29th, 1864. The case is reported by the operator. Case. — Lieutenant Adam Miller, 2d Massachusetts A’'olunteers, aged 23 years, was wounded on August 9th, 1832, at the battle of Cedar Mountain, by an elongated musket ball, which entered below the right orbit, and traversing the nasal fossa“, 'emerged thi'ough the left orbit, destroying the globe of the left eye, and lacerating the left lower eyelid. Fie was made a ■prisoner, and taken to an hospital at Charlottesville, Virginia, where his wound ultimately cicatrized, with great deformity. Having been exchanged, he entered the New York Eye Infirmary, and, on April 10th, 1863, ether having been administered, a plastic operation was peiformed, by Dr. Henry 15. Sands, for the restoration of the eyelid. The operation was eminently successful, and, on April 22d, 1863, the parts were sufficiently healed to permit the insertion of an ai’tificial eye. Although the lachrymal sac and puncta were destroyed, little inconvenience was experienced from stillicidium. Lieutenant Miller was, sidjsequently, transferred to the 7th Regiment A'^eteran Reserve Corps. A photograph was taken in April, 1866, and is numbered 135 of the Surgical Series. He is a pensioner; his disability is rated one-half. Case. — Private JT. M. Wyatt, Page's battery, 1st Virginia Artillery, aged 46 years, was wounded on September 13th, 1883, by a fragment of shell. Fie was admitted into the No. 1 hospital, Richmond, Virginia, September 17th, 1833. The lower jaw, from the first molar tooth of the-right side, nearly to the angle of the jaw on the left side, the soft tissues forming a portion of the cheeks, the whole lower lip and the original covering of the chin were carried away. His tippeai’ance was frightful and most pitiable. Sloughing had commenced. In a few days, however, the sloughing ceased; and, although suppuration was profuse and very offensive, the granulating process became fully established. On November 10th, he was well enough to go home on a furlough. He retnrned to the hospital early in January. Cicatrization had occurred. Irregular and lumpy cicatrices extended into the cheeks from the corners of the upper lip, which had been involved in the wound, down to the throat ; and the tongue aj)pearing in the chasm representing his mouth, adhered to the transverse edge of the cicatrix two inches below the border of the uj)per lip. It was determined to make a new lower lip, if possible, by dissecting the tissues of the throat and Sect. III.] PLASTIC OPEKATIONS. 371 cheeks, sliding them to a level with the hordei- ot the upper lip, and securing them in position by sutures. The operation was performed on January lOlh, 1834, without chloroform, as it was desirable that the patient should not incur the danger of blood passing into the air pas.sages. An incision, three inches long, was made downward in the centre of the tissues of the throat, terminating about the middle of the thyroid cartilage. From the termination of this incision another was carried, first on the right side and then on the left, upward and backward, toward either angle of the jaws, each to the extent of three inches, and the two tl.aps were marked out. These flaps were then dissected one-fourth of an inch in thickness, from the subjacent ti.ssues, so that, when the dissection was completed, the two fl.aps, each being seized at the central incision, could be raised and brought up so as to ju’esent an opposing margin or surface to tlu' upper lip. As was anticipated, the flaj)8 now required to be incised to prevent the edges, by which they were to be united, from overlapiiing; accordingly, about a (piarter of an inch in width >vas removed from each flap along the edges. Being again brought up to the border of the iqiper lip, the flaps were united in a central line by interrupted sutures of silver wire. Two incisions were then made from either angle of the new mouth upward ; the lum])y and unsightly cicatrices were cut out, and the wounds united by silver wire. Adhesive strijis and a bandage completed the operation. Direction was given as to diet and drink, and an anodyne was administered. On the fourth day perfect union occurred, and, with the exception of the suture at the upper end of the central lino, which idcerated thi-ough, all was doing well. The sutures produced no irrit.ation, and were not removed until the tenth day, when the j)arts were ])erfcctly consolidated. The wound below suppuratwl and granulated kindly. On March 1st, the patient loft the hospital for his homo greatly improved in appearance and in his power of articulation. The case is reported by the operator. Surgeon C. B. Gibson, P. A. C. S., and illustrated in the Confederate States Medical and Surgical Journal for July, 1834, p. 104. Case. — P rivate John S- -, Co. B, 1st New York Mounted Rifles, aged 29 years, received, on Jnly 12th, 1863, at Indiantown, North Carolina, a gunshot fracture of the lower jaw, by a conoidal ball, which carried away the right anterior portion as far back as the second bicuspid tooth, and, on the left side, as far back as the second molar. He was treated in the regimental hospital until August 29th, 1863, when he was admitted to the Balfour Hospital, Portsmonth,' and pared in the same manner. The two fresh cut surfaces were brought into accurate apposition and secured by sutures. The adherent right extremity of the upper lip was dissected up from the alveolar border of the jaw, and from this point an incision was carried outward and iqiward, along the ui)per margin of the cicatrix crossing tlie cheek as high as the zygoma. The skin and subjacent tissue were detached fixa^ly toward the orbit and temple. Another incision was then commenced below the left angle of the mouth, at a point where the incision detaching the under lip terminated, and carried to the right, across the chin, at a finger’s breadth below the free callous border above described as constituting a substitute for the lost jaw. This incision was continued on obliquely uj)ward and outward, over the cheek below, and close to the cicatrix as far as the zygoma. A third incision, beginning at the starting point of the preceding one, below the left angle of the mouth, was carried perpendicularly downw.ard a distance of two inches upon the neck. In its course a cyst, of the size of a dollar, was encountered, filled with a brownish, transparent, viscid fluid, such as is met with in r.anula, and was dissected out entire. The angle included between these two incisions, as well as the integument below, crossing the right cheek, were extensively detached from the parts beneath. An upper and lower flap, including the entire right cheek and nearly the whole chin, were thus formed. They were separated by the cicatrix crossing the cheek, which had been left in situ. After paring oft' the surfaces of the cicatrix, the edges of the flaps were brought together so as to cover it u|), and secured by sutures. At the right angle of the mouth, reconstructed in the manner already described, the flaps above and below were matched to the lips and also secured by sutures. Sutures were introduced in close proximity throughout the entire extent of the flaps, so as to maintain their edges in accurate adjustment. Four of the sutiu’es w'ere twisted and were imserted, one at the right angle of the mouth, two upon the right cheek at ])oints where they would afford the best support to the flaps, and one arthe angle of the Haps, below the under lip. The newly constructed mouth was of medium dimensions, the lips maintaining themselves in contact and retaining the salivary secretion. The adjustment of the different parts to each other was effected without any strain upon the sutures at anj' one point. No adhesive plaster was used. Liquid nourishment was directed to be given through a tube, and water dressings to bo applied to the face. The case ])rogressed favorably, and by November 10th, adhesions had taken place throughout almost the entire extent of the flaps, and all the pin sutures, with mo.st of the thre.ad sutures, were removed. A free discharge of pus was taking place at the lower e.xtremity of the incision under the chin, where the cyst was removed. Strips of adliesivo plaster were applied at jioints where their su])port seemed needed. A suj)erficial slough of the size of a copper cent had formed over the zygoma, which could not, however, mar the residt of tlu; o])eration. The suppuration below the chin gradually diminished, and ceased entirely in a few days, every part of the wound healing completely. On December 12th, 18G5, the patient left the hospital to return to his home. The ability to maintain the lips in contact, and thus retain the saliva, constituted an immense amelioration of his condition. His inn)roved appearance, and some improvement of articulation, were also results highly gratifying to the patient. Case. — Sergeant Robert Beck, Co. G, 27th Iowa, aged 2.5 years, received, at the battle of Pleasant Hill, Louisiana, April 9th, 18.)4, a gunshot wound ; the missile entered the left temple on a level, and one inoli jwsterior to outer eminence of the left eye, and pas.sed out one-half of an inch below the right eye, destroying in its course the left eye, the lachrymal sac, duct of right eye, and the bone.s, and produced ectropion of the right eye. He was admitted to the IMariue Hospital, St. Louis, on Ajtril 7th, 1835. On April 27th, Surgeon J. H. Grove, U. S. V., performed a ])lastic operation for deformity of right eye. Sinn)le dressings were applied. The result was j)erfect. He was discharged on May 13tb, 1805. The case is repoi tcd by the oj)erator. In March. 1871, Pension Examiner J. W. Smith reports that necrosed bone has been discharged, during the past year, from wound of exit; the left nostril is closed, except by forced ins|)iration. Ho rates his disability as total and permanent. Ca.se.— Private W. H. Blanchard, Co. H, 7th Michigan Volunteers, aged 23 years, was wounded at the battle of Antictam, Maryland, September 17th, 1862, by conoidal ball, which entered a little below the zygomatic process of the sujierior maxillary bone of the left side, passed through, carrying away the symphysis and palatin(> processes, and emerged a little above the right angle of the upper lip. He was ti;eated iu field hospital until September 23d, when he was admitted to hosjiital at Frederick, Maryland, where several small pieces of bone were removed. The wounds healed by January 1st, 1833. On January 3d, the patient was chloroformed, and the adhesions in line of fissure and cicatri.x were set free by incisions, and the cut surfaces on either side of the cicatrix brought together by sutures after an incision on the right side of the nose for mor(“ conqdete adjust- ment. The result was very satisfactory, and by January 30th, the parts had united with very little deformity. llc! was discharged from service January 12th, 183'3, and from hosj)ital on Feliruary 2(>tli. The records of the Pension Office state that in July, 186.5, Blanchard was a pensioner; that he was restricted to soft diet, and was badly di.sfigured. His disability was rated total and pennanent. Ca.se. — Private Rowland W , Co. E, 4th New York Heavy Artillery, aged 46 ye.ars, was wounded at Ream’s Station, Virginia, August 25th, 1864, by a fragment of shell, which destroyed and completely carried aw.ay the inferior maxillary bone and soft parf.s, commencing two inches anterior to the angle on the right side, ciirrying away the chin and all the soft ])arts down the neck, on a level with the hyoid bone, destroying the floor of the mouth conqiletely, allowing the tongue to i)rotrude and hang (lown on the neck ; deglutition and ai-ticulation were im|)ossible. Three of the right lower incisor teeth, with the 374 WOUNDS AND INJURIES OF THE FACE [Chap. II, corresponding nlreoli loosely connected with the tissue, remained, and were allowed to stay in that position until the healing ])rocess to(dc place*, as they gave a partial siii>i)ort to the tongue and siihinaxillary gland, which was not injured. The wound extended acro.ss to the left side, carrying away all the teeth and jaw bone, except those previously mentioned, to a point as high up as the angle of the inferior maxillary on the left side. He was admitted to Lincoln Hospital, Washington, August 28th, 1864. His general health was bad from .scurvy. The patient did well, and improved rapidly. On December 9th, he was furloughed for thirty days, and, at the exjiiration of his furlough, he was readmitted to hospital in good condition. On January 20th, 1865, an operation was perbmned to construct a floor for the mouth — no anaesthetic was used. Pi-eliminary to the operation, twp molar teeth were extracted from the right-hand fi'agment of the lower jaw. An incision was made two and a half inches in length down the median line of the neck, terminating one inch above the thyroid cartilage. Two lateral incisions, one upon e.ach side, of equal length, right-angled to the vertical incision, these incisions corresponding to the bas(! of the jaw. These flaps were then carefully dissected up, brought together .at the middle incision, and secured by three hare-lii) needles, the parts being su])i)orted by adhesive straps. Frequent application of dry lint was made to ])rotect the parts from the injurious effects of the saliva, wliicli was being constantly secreted. The healing ])roceedcd rapidly, the parts uniting by first intention. Power of articulation and degnstation was much imjiroved. Tlie needles were removed on the third day. On April 22d, 1865, the jjarts being in a favorable condition, ether was administered, and a second operation was performed. Two incisions, one on the right and one on the left, j)arallel to the inferior border of the inferior maxillary bone, each three inches in length, severed both the facial arteries, which were secured by ligatures. The upper flaps were carefidly dissected up, .as far back as the angle of the jaw upon each side. The anterior edges of these flaps were freely incised, as well as the superior edge of the parts remaining after the first o])eration. The Haps were then brought into apposition and ret.ained by four hare-lip needles, two in the upper flap forming the lip, .and one upon each side, uniting the lower edge of the flap to the freshened edge of the p.arts after the first operation. Dry lint dressings were applied, and the patient was fed through a gum catheter. The hare-lip pins were removed from th(^ longitudinal incision on the third day, the others being removed on the fourth day, at which time the remaining pins, together with all the sutures, were removed, the parts being supported throughout the remainder of the treatment by strtips of adhesive plaster. On the morning of the 27th of A])ril, secondary hfemorrhage occurred from-the left facial artery, which was readily controlled by digital compression. Owing to the constant secretion of saliva from the sublingu.al gland, which was carefully ])reserved during the operation, a slough was produced at the junction of the inferior angle of tin; flaps. This was checked by the application of a weak solution of nitric acid. On June 23d, tin* patient was discharged at his own request. A fistulous orifice, one-fourth of an inch in diameter, only remaining, in consequence of the constant secretion of saliva from the soblingu.'d gland, which prevented the parts from closing by granulation. He is able to articulate quite plainly, which he h.as hitherto been unable to do since the date of his injury. Until the completion of this operatioiuthe patient was compelled to assume a recumbent position to receive his nonrislnnent, or even a swallow of ^vater. He can now take his food and drink without any ir;\tion of twenty-four hours. The loss of blood, though considerable, did not produce extreme depression of the pulse. The operation occu])ied about three hours, frecpient interruptions being necessary to keep up the effects of the ethei-. No adhesive straps were employed. Tepid water dressings were directed. During the three days succeeding the operation, the swelling of the parts, though considerable, was not excessive, and febrile reaction was moderate. After that the swelling began gradually to diminish. At the expiration of the first twenty- four hours, the alternate sutures were removed, and every day following additional ones were got rid of at points where they could be safely dispensed with. On the sixth day, all the sutures had been removed, and union by adhesion bad taken place throughout every part of this extensive wound. The only point where su|)puration occurred was at the lower angle of th(( wound under the chin, which, however, was not of long duration. Before the expiration of the second week, the ])atient had left his bed and was about the ward. He regarded his condition as very materially improved. The saliva no longer passed uncontrolled from his mouth. Articulation and mastication were very much ameliorated. Both lips, for want of the su])i)ort of the front teeth, fell in, and the symmetry of the mouth itself was considerahly disturbed, three-fifths of its length being situated to the right of the median plane and two-fifths to the left. On April 16th, he was transferred to the Governor Smith Hospital, Brattleboro’, Vermont, and discharged from service on July ‘Joth, 1805. On December 12th, 1805, he was induced to ent(!r the N(!W York Hospital, with a view of having an operation jierformed for the improvement of the mouth; preliminary to which, Mr. J. A. Bishop, of New York, ingeniously adapted a plate of vulcanite to both jaws that would supply the deficient front teeth and aftbi’d support to the lips. On January 9th, 1800, the second operation was performed by Dr. Gurdon Buck, the object being to extend the mouth about five-eighths of an inch on the left side, so as to restore its symmetry to a good degree. The angle of the mouth was circumscribed by an incision along the vermilion border, involving about five-eighths of an inch of the upper and lower lip. A double-edged knife was then inserted flatwise at the angle between the lining membrane and the cheek, and the lining membrane detached in the direction in which the enlargement was to be made. The cheek alone was then divided with strong scissors, in a line with the commissure of the mouth, to the extent of three-fourths of an inch, and a narrow angular strip pared off from the fresh cut edges above and below. The subjacent mucous membrane was next divided to the same extent, and the newly formed angles of the cheek and lining membrane secured together by a twisted pin suture. The remaining edges of the mucous membrane were pared and adjusted to the corresponding edges of the cheek, and were both secured together by fine interrupted sutures inserted close to each other. Everything went on favorably after the operation, and the result was highly satisfactory to the patient as well as to the surgeon. He is a pensioner. A cast, representing the condition of the injured parts previous to the first operation, is numbered 265 of the Surgical Section of the Army Medical Museum. Another, showing the patient’s appearance two months after the operation,^ is numbered 485. A third cast, taken January 8th, 1803, prior to the second reparative operation, represents substantially the same condition. These casts were contributed by the operator. A photogi-aph of the case is numbered 282 of the Photogi-aph Series of the Army Medical Museum. Case. — Private Carleton B , Co. B, Purnell’s Maryland Legion, aged 20 years, was admitted into the hospital at Frederick, August 4th, 1802, in a prostrated condition. He had a bed-sore over the sacrum; his body was bathed in sweat and covered with sudamina. His tongue was dry and his teeth covered with sordes. It was reported that he had been sick in camp since June 5th, and that he had recently taken as treatment for pneumonia, two scruples of calomel, onescruplt! of mercury with 376 WOUNDS AND INJURIES OF THE FACE, [Chai-. II, Fig. Appearance of patient -with loss of ii])per maxilla and soft tissues, from sloughing, prior to operation. .Soe casts and jdiotograplis, A. BI. M., No. 4Go5, Sect. I. chalk, and sixty-live grains of blue pill. Stimulants and nutritious diet were administered. On August Gth, a jagged ulcer was discovennl on the right edge of the tongue. On the lOlh. a slough ajipeared on the gum at the root of the right upper bicuspid tooth. The ulci'r rapidly extended to the cheek and the roof of the mouth ; by the 21st, it had nearly reached the orbit, the entire upper maxilla being exposed. From this date, the parts gradually assumed a healthy action, and, by the 27th, ulceration had entirely ceased. It was then close to the eye, and had removed the right ala of the nose and the right half of the upper lip from the angle of the mouth, beyond the median line, on the left side. On October 1st, the entire right superior maxill.a, the vertical plate of the palate bone, and a narrow strip of the left maxilla, being quite separated from the healthy bone, were removed (Fig. 171). The great loss of substance on the right side of the face caused frightful deformity. The right eye \vas destroyed and sunken ; the right half of the upper lip, the right ala of the nose, and the adjacent portion of the cheek, besides the right superior maxillary bone, were gone, leaving an exten- sive opening directly into the cavity of the mouth and right nasal fossa. The margin of the opening, which was everywhere cicatrized, was constituted below and outwardly by the border of the lower lip, which was stretched obliquely upward and outward, and termi- nated at the malar bone, where the superior maxilla had separated from it and where it was closely adherent. From this point, which corresponded nearly to the middle of the , , , . , , , , Fig. 1()8. — Cap for holding cheek, tlie margin extended upward and uproof-piece (Fig. 169. From Fig. 169.— Artificial roof of mouth, with teeth. (From a photograph furnished by ilr. Gunning.) inward, in a curved direction, to the side of the nose, approaching within a finger’s breadth of the a. P^iotograph from Mr. Gun- inner canthus, and continuing thence downward along the ridge of the nose, a little to the right of the median line, and terminating at its tip. The columna nasi being destroyed, the left ala, and the rounded margin of the left half of the lip, which terminated nearly exactly at the median line, constituted the limit of the opening on this side. About three-fourths of an inch of the vermilion border of the lower lip, at its right extremity, appeared to have belonged to the upper lip, and to have assumed its present position, in a continuous line with the lower lip, in consequence of the adhesions which had taken place in the cicatriz- ing process. The integu- ment and subjacent tissues were supple throughout the margin, up to the line of their adhesion. The walls of the cavity exposed to view by this opening, presented the following : inward, toward the median line, was the septum nasi, deflected somewhat toward the left side, incomplete anteriorly and inferiorly, where its cartilaginous portion had been de- stroyed, and where the anterior portion of the inferior turbinated boiK!, with the passage to the nasal duct of the left side, is seen. Upward, the scrolled inferior edge of the middle turbinated bone presented itself. The outer wall was a smooth, uniform surface, which was lost below in the general cavity of the mouth; the floor of the cavity was occupied by the tongue. The jiosterior portion of the bony palate, con- stituted by the palatine process of the palate hone, presented its free anterior edge cicatrized and stretching horizon- tally across the middle of the cavity Fig. 170. — Nose-iiiece devised by Mr. T. It. Guuiiiiig. (From a photograph.) Fl(i. 171. — Inferior maxilla ex- fiiliated utter disease. Xpec. Go7, Sect. 1, A. M. M. Fig. 179. — Appearance of Burgan after the fifth and final operation. (After photographs and i)laster casts presented by Dr. Buck.) Sect. III.] PLASTIC OPERATIONS. 377 posteriorly. The line of separation between the two superior maxillary bones having taken place a little to the left of tlie median suture, the left middle incisor tooth had been carried away. The lining membrane of the cavity presented everywhere a remarkably healtby appearance. The palatine process of the palate bone, with the velum, having escaped, deglutition was jierformed without disturbance ; his speech, howeVer, was very indistinct, and resembled that of an individual with a bad cleft palate. A pulfy condition was observed below the inner half of the lower lid of the right eye, connected, probably, with chronic irritation of the lachrymal sac ; the puncta, though open, and admitting a fine probe, did not allow it to pass on into the sac. On December 22d, Burgan was discharged from service to go to New York City, entering the City Hospital on December 31st, where a plan was devised for the restoration of the jiarts destroyed. Before commencing the operation, dental fixtures, partly temporary, were ingeniously constructed by Mr. Thomas B. Gunning, of New York, and fitted to the cavity f)f the tnouth to afford solid support to the soft parts that were transferred for the reconstruction of the mouth, and the closure of the cheek and nostril. Fixtures, in three parts, were made of vulcanite, two principal and one supjdementary. The upper ])iece filled out the right half of the nose ; the lower piece formed an artificial palate ; the third part connected with the ludate piece by bent spiral wire; the patient wore them two weeks prior to the first o))eration. On March 2Gth, ether having been administered, the first operation was performed, which consisted, first, in liberating and shaping the left half of the upper lip ; second, in suppljdng material for the right half of the lip ; third, in bringing forward the middle and lower portions of the right cheek, and adapting them to the newly transposed neighboring half of the mouth. Nothing further was attempted at this operation. It occujiied at least two hours and a half; much of the time, however, was employed in the rcadministration of the ether to keep the patient quiet. No adhesive plasters were applied, the sutures being exclusiv(dy relied on. Warm water dressings were directed to the pai ts. On Ajtril 23d, the parts involved in tbe first operation being free from swelling and having regained their suppleness, a second operation was ])erformed, the object of which was to improve the mouth by extending it toward the right side and converting the circular turn into an angle, which was accomplished while the patient was under the infiuence of ether. On June 18th, a third operation w’as perlbrmed to close the remaining opening in the cheek and cover the side of the nose with a llap from the forehead, which was also accom- plished while the patient was under the influence of ether. On August 8th, an operation was performed to remove the deformity at the root of the uo.se, resulting from the jn-evious operation, and, on October 27th, another, to remove a furrow and notch in the nose. In .June, 18o4, Burgan enjoyed good health, and had, for several months, been able to discharge efficiently the duties of an assistant nurse in a large ward of the New York no.spital. The hypertrophied condition of the nasal ])atch still persisted, and might be regarded as a permanent condition ; quite the reverse of what was anticipated, it had the advantage of maintaining the side of the nose in a plump form. When the patch was piicked the sensation was no longer referred to the forehead as at first, but to the jiarts irritated. The cicatricial bands on the inside of the mouth had been kept from contracting by the persevering eftbrts of the patient, who had faithfully executed the directions given him on the subject, which were to introduce one or two fingers into the mouth and stretch the bands to their utmost endurance, and rejieat the jirocess several times daily. The only dental fixture worn by the patient .at that time was the principal jiiece, which covered the roof of the mouth and sujijilied the lost teeth of the right ujijier maxilla (FiG. 1G9). It was worn constantly with entire comflu’t, and was removed and replaced at jile.asure. When the moutli was open to its fullest extent, the forefinger could be introduced edgewise between the front teeth. Mastication of all descrijitions of food was performed with facility. The sjieech, which, without the dental fixture, was hardly intelligible, scarcely betrayed any defect when it Avas worn. An artificial eye was adapted to the right orbital socket, and was worn by the patient a jjart of the time. A colored plaster cast of his face was prepared previous to the patient’s discharge, and, with the pathologic.al specimen, consisting of the greater portion of the right superior m.axilla, showing necrosis, was contributed to the Army Medical Museum by Assistant Surgeon R. F. Weir, U. S. A., and is numbered 557 of the Surgical Section. A detailed history of the case by the ojierator. Dr. Gurdon Buck, will be found in an illustrated jiajier in the Transtvetions of the New York State Medical Society, for 18G4, jiage 173. Burgan tvas a j)ensioner in December, 1871.* Case. — Private John W- I’lG. 173. — Defiirmity after gunshot wounds of the face. (From a pliotograph.) Co. C, 140th New York Volunteers, aged 24 years, was wounded at the Wilderness, May 5th, 1864, by a colloidal ball, which entered the. right side of the face, midway be- tween the eye and the ujiper lij), passed dotvinvard and outward, emerging on the left side of the face, immediately below the malar bom*, producing a comjiound fracture of the superior maxilla, tind destroy- ing the four front teeth, eye-tooth, and three large teeth on the left side, with their alveolar jirocesses, and p.art of the ji.alate process. He received also a wound in the leg. Flo. 174. — Result of a plastic operation in the ease fiiruml in No. ]73. *^Tlie case is fig-nrcd in Prof. Oito'h paper, '’^Me.tUode.n dvr plasfuchen chirurfjiv," in VON PlTHA uiul P.lLMiOTII, Cliirurf/iv, Hd. I II, 2 II<*ft, S. 142. 48 378 WOUNDS AND INJUEIP]S OF THK FACK, [ClIAl*. II, On Fcbniai'V 24tli, IKif), lii* was adinittcil to Carver llosjjital, Wasliingtoii. The woiiinl was eiilirely liealed when adnnttecl, hnt tin! cieatrix ]H()dnced great deforniity of the npjier lip, interfering with jiroper iirtieidation. On Marelj Stl], Surgeon O. A. Jndson, U. S. A., decided to operate, and liaving etlierized the patient, made an incision from wound of entrance down- ward through the n])per lip and a large portion of the cicatrix. The adhesions that were found heneath were dissected up, and the ]iarts hiought in apposition hy pin sutures. Simple dressings were apjdied to the wound. The case progressed favorahly, and, hy March 22d, the wound had nearly healed hy first intention. The lip presented a much better appearance, the articulation was greatly improved, and the patient could readily partake of solid food. On April 8th, he was transferred to Mower Hospital, riiiladelphia, whence he was discharged from service on .June 24th, 18C5. On January 3d, 186G, Pension Examiner 11. T. IMontgoinefy reports “a large opening from month to nose; great permanent deformity of face; voice and mastication impaired.” He rates his disability three-fourths, partly hy reason of the wound of the foot. Ca.sk. — Private Edgar M. Chaney, Co. A, 32d AVisconsin Volunteers, aged 29 years, was wounded in an engagement on the Comhahee Diver, South Carolina, February 3d, 1865, hy a conoidal hall, which entered over the right malar hone, and, ]iassing obliquely down to the left, tore up the attachment of the tarsal cartilage near the inner canthus, destroyed the substance of the lower eyelid, passed through the nose, separated a part of the right alar cartilage and septum nasi, and emerged nearly ujion the bridge of the nose, half an inch from its point. He was conveyed to Beaufort, and, on February Clh, adnutted to ilivisiou No. 1 hospital. On February 24th, he was transferred to Grant Hospital, New York Harbor, and, on April 17th, to H arvey Ho.spital, Madison, Wisconsin. When admitted his constitutional condition was good. The right alar cartilage was (h-awn up belotv, so as to stand !it the hiidge half an inch higher than the septum nasi, while attachment at its base was natural ; the left alar c.artilage was somewhat drawn up at the apex of the nose ; the right lower eyelid, drawn down and outwiird, was attached to the right malar hone and everted, with a large fold of its mucous memhi'aue presenting; and the tar.sal cartilage h.ad united hy cellular tissue at its middle third. Rest and occasional laxatives having improved the ]>atieut's condition. Surgeon H. Culbertson, U. S. V., decided on performing a plastic oper.atiou. On May 2d, 183.5, chloroform was administered, and the nostrils plugged. An incision was commenced at the bridge of the nose, and carried to a level with the cheek through the right aliir cartilage and mucous membrane of the nose, and which extended to the point. The cartilage being then depressed to its natural level, another incision was extended through the skin and cicatrices, and the edges of the wound at the tip of the nose were freshened. A flap, with much cellular tissue, was next raised, gently twisted upon itself, and secured in a bed made hy depressing the separated alar cartilage, as seen at a. The points of alar cartilage were adjusted and secured by one suture ; and the edges of the gap made by the removal of the flap were approximated hy sutures. An incision, parallel with the lower border of the orbit, was then made, and the cicatrix removed, and the remaining portion of the lower eyelid brought up to its natural position. A flap was afterwards raised as deeply as superficial fascia — but broader than shown in the figure — reverted, jJaced in situ, as seen at h, and secured by sutures. The edges of the wound at c were api)roximated ami secured by sutures, and additional support was furnished hy adhesive strips. After the operation, the patient’s hands were secured to the sides of his bed, a grain of morphine was given, lint moistened with sweet-oil was apidied over the pedicles and margins of the flaps, aud a slop diet was ordered. The flap beneath the eye united by first intention, and also a part of the flap of the nose ; the other parts of the latter flaj)s healed by granulation, and w'ere ke|)t in situ, by fine jjins. The pedicles were divided on the 21st day, and thrown back into their original beds — i. e., tlie part of flaps not required. This man was mustered out of service on June 8th, 1865. The lower eyelid was nearly natural in appearance ; the nose was slightly depressed on the bridge, and the beds from which the flajis were taken had nearly healed. The patient tippeared as indicated by the wood-cut, on which the lines of the incision are .also traced. Case. — Private A. Gilbert, Co. B, 126th Ohio Volunteer.s, aged 24 years, was wounded at the Wilderness, May 12th, 18, k1, by a conoidal l)all, which entered the left side of the face .at a point corresponding to the body of the malar bone, passed inward tind forward, and emergcal at symphysis of superior maxilla. He was treated in field hospital until May 16th, when he w:is .sent to Lincoln Hospital, Washington, where simple dressings were ai)plied. The wound healed rapidly, leaving an opening through the iqiper lip. On May 28th, he w.as transferred to Mower Hosjiital, Philadeljdiia. On October 5th, Dr. Morton clo.sed the opening in the upper lip by t.aking a flap of tissue from the left side of the face and making union as for hare- lip. Water dressings were .applied. Gilbert was discharged from service May 27th, 1865. Ca.sk. — I’rivate llllliani M. Cool-, Co. K, 3d Georgia Regiment, received, at Chancellorsville, May 3d, 1863, a wound in the face by a fragment of shell, which extensively mutilated the ui)per lip and nostrils. He was admitted to Hospit.al No. 1, Richmond, Virginia, where a plastic operation was performed about six weeks after the injury. He was furloughed on August 18th, 1863, for sixty days, and afterward returned .to duty in his regiment. Cask. — Private Robert Spornitz, Co. B, 5th Minnesota Volunteers, was discharged from service at Fort Ridgely, Minne- sot.a, on October 24th, 1862, on account of a gunshot wound through the upper jaw, with loss of all the upper teeth, received in a fight with Indians. The operation of staphylorraphy was successfully performed. Fig. 17.'). — Incisions in a plastic ojieration on the lower eye-lid and nose. (From a drawing by the operator.) Skct. III.] PLASTIC OPERATIONS. 379 Plastic Operations.— In the foregoing tliirty examples of plastic operations, the regions in which attempts at reparation were made were, in the eyelids, in six cases ; the nose, in five; the cheek, in three; the lips, or palate, or other parts about the mouth, in ^ twelve ; and the chin, in four cases. On page 331, another instance of blepharoplasty is cited, and on page 348 an unsuccessful case of staphylorraphy. Of the thirty-two cases, twenty-nine were for deformities following gunshot injuries. In the majority of the cases a certain measure of relief was afforded. Dr. Buck’s operation (p. 374) must be reckoned among the chief triumphs of modern plastic surgery. The history of Corporal Henry Gibbs (}L 370), communicated by Surgeon S. F. Forbes, 67th Ohio Volunteers, subse- quently pension examining surgeon at Toledo, Ohio, is extraordinary. The removal of the entire lower jaw “without any apparent external deformity” after four weeks, is a result rarely achieved, and it is to be regretted that the patient is not registered on the pension list, and that casts and photographs were not forwarded with the history. There were other cases in which plastic operations on the face were contemplated or unsuccessfully attempted, some of which are illustrated by photographs in the Army Medical Museum,* where the distressing deformities produced from excessive loss of tissue about the soft parts of the face, prompted surgeons to yield to the solicitations of patients, and to intervene with but slight anticipation or hope of success. There were other examples of gunshot wounds involving the ethmoid, or the nasal or other small bones of the nasal region, or the upper portions of the superior maxilla, in which ugly fissures were left, which could not be closed because of the protracted suppuration and frequent exfoliation of minute portions of bone. Many such patients have presented themselves at the Museum. A remarkable instance is recorded on p. 329 [ante), the case of Sergeant Prince.f In this, and in several similar cases, where the patients were examined at periods from three to seven years after the reception of their injuries, it was found that the incon- venience likely to be caused by an autoplastic operation would scarcely compensate for the possible modification of external deformity. In cases in which the patient had long respired through the cloaca leading to the nasal passages, it was found that the anterior nares had so contracted, from disease, that a closure of the traumatic orifice was imprac- ticable, or else that injuries of bone involving the lachrymal sac or its canal indicated that any operative interference would be almost hopeless. A study of the sufficiently detailed histories of cases on the Pension Polls, and personal examinations of many patients and pensioners mutilated by gunshot wounds of the face, convince me that the occasions on which autoplastic operations are likely to be employed advantageously are few in number. How and then, by removing disorganized parts, and paring and approx- imating the sound tissues by twisted sutures, favorable results may be attained. But, as a general rule; the deformities following gunshot wounds of the face and suggesting some plastic procedure are either accompanied by such extensive loss of tissue or chronic disease of the osseous structures, as to forbid any hopeful undertaking in the way of reparative surgery. Thus the records of gunshot injuries of the face in the late war, nearly ten thousand in number, furnish only the few examples above enumerated. Dr. Chisolm {op. cit.), the author of the principal systematic treatise on military surgery in the Confed- erate service, does not refer to the subject, and from the accessible sources of information * Photographs of Surgical Cases and Specimens. I’repared by 15vt. lA. Col. G. A. OTIS; by direction of the Surg-eoii General, Washington, 18(J5-1S7(). Vol. I, p. ild; Vol. II, pp. 2!), 30; Vol. Ill, p. 3."); Vol. IV, p. 36. t See Photographs of Surgical Cases, etc., op. cit. Vol. VII, p. 12. 380 WOUNDS AND INJUKIES OF THE FACE. [Chap. II, regarding the surgery in the Confederate army only two , cases are to he gleaned. ( Wyatt, p. 370 ; Cook, p. 378.) Surgeon David Prince, U. S. V., writing, in 1868, an ingenious “brief exposition of Plastic Surgery,” does not advert to its applications in military surgery, and as he has evidently carefully studied the subject, it may he assumed that these applications are few. Among the photographs filed in the Museum are several in which unavailing attempts have been made to close apertures in the cheek, caused by the perforation of musket balls. Probably the incisions were made through the inodular cicatrical tissue bordering the apertures, and had it been practicable to extend the operations by “gliding,” more successful results might have been attained. From the pensioners at the Soldiers’ Home and the National Asylums for Disabled Volunteers, no instances of loss of tissue from gunshot wounds have been reported where autoplastic operations could be undertaken with reasonable anticipations of success.* * A single example is reported of an attempt at otoplasty, or rather otorrhaphy, in the case of a teamster whose ear was bitten off’ in a fight. The auricle was completely detached and was covered with dirt. It was immediately washed in warm spirits and water and accurately stitcheel on by interrupteel metallic sutures, and covered lightly by carded raw cotton and bandaged. But, at the end of three days, there was no attempt at union, and the detached pinna showed no sign of vitality. There were a few instances of salivary fistulse following gunshot wounds. Abstracts have been cited of the histories of the cases of Colonel Guiney (p. 330), and of Private Hart (p. 368). The complication was uncommon, however, the laceration produced by the projectile usually sufficing to obliterate the salivary ducts. In the few cases that occurred,- the ordinary measures of treatment, by occlusion, cauterization, and frequent dilatation of the excretory orifice of the canal of Steno, were employed with success. Whatever was communicated in regard to the methods of operating in the autoplastic ])rocedures has been specified in the abstracts of individual cases. The precepts of Jobert appear to have been commonly followed, though Dr. Buck’s extraordinary operations abounded in original expedients. [Since the first issue of this volume this eminent sur- * U is .unnecessary to enlarge <;n the literature of the subject, unless to indicate to medical otiicers the principal works accessible in the Librarj" of ithc Kurgeun General's Office, among others the 7^7’inceps edition in vellum (1597) of Taliacotius, the "Venice edition of Tagliacozzi, and several more .modem reprints or translations, of this famous llolognese surgeon's writings and plates, and DilTeubach’s earlier essays : Taliacotius, De curtoruvi chirurgia per insitionem, Veuet., 1597; PlEiiUS (of Antwerj’), Lihri chirurgici, Tract XII, 1G12; Paulus Aegineta, Tab. VI, Cap. 2G; I'AlililClus IllLUANUS, Observat. chirurg.^ Cent. HI, Obs. :U ; SciiENiaus, De Narihus, Obse^^^ 8 ; AMBROSE Pare, translated by Tn. .JOIINSOX, p. 526; PALLOriUS, De decoratione. Cap. 2; SCHOlTI, Italia illustrata, HilO; Benedictus, De prax. »icd., Lib. IV, Cap. 39; GourmelenL’S, Chirurgia, Lib. I; LEONARDO FIORAV./VNTI, llscgretti de Chirurgia ; BLEGNY, Zodiacus medico-gallicus, Genevm, 1680; Celbus, De re mcdica., Lib. VII, Cap. IX; Fabricius (ab Aquape..dcnte), Op. C/tri*., Cap. Gl; Blandix, De Vautoplastie, Paris, 1836; BLSUNAN, Observations on the Restoration of the Nose, London, 1833; Ammon UND Baumgarten, Die Plastische Chirurgie, Berlin, 1842; Fritze, Die Plastische Chirurgie, Berlin, 1845 (with 48 engravings); JOBERT, Traile de chirurgie plastique, Paris, 1849; ZEIS, Ilandbuch der 2 >lcistischen Chirurgie, Berlin, 1838; MICHON, Menioirc ci observations sur quelqves cas d' autoplastic de la face, Paris, 1847; Sl^DiLLOT, De V application de la methode anaplastique, etc., Strasbourg, 1845.; Serre, Traiti sur I'art de restaurer les diJformiUs de la face, Montpellier, 1842 ; Nasemann, Questiones de rhinoplastice, Halis, 1849 ; DROOP, Dc *usu iabii sujyerioris in rhinoplastice, Halis, 1844; Labat, De la rhinoplastie, Paris, 1840; Dieffenbach, Die Oqyerative Chirurgie, Leipzig, 1845; iCAiaMJE, Account of two successf ul Ox)eraiions, etc., London, 1815 ; GarengeoT, Traiti dcs operatioiis de chirurgie, Paris, 1748 ; Weiseman, De coaliin parlium a reliquo cor pore pr or s ns disjunctiarum, Lipsia?, 1824 ; BUNGER, Gelungencr Fall einer Nasenbilduvg, in v. GraeiTS und V. 'VValTHER’s Journal. Jld. IV, p. 5G9; Laruey, Clinique Chirurgicale, Paris, 1829, T. H, p. 12; SiMS, Silver sutures in Surgery, New York, 1858; SkeY, Operative Surgery, ijd cd., p. 521; IIOLME.S, A System of Surgery, Vol. V, p. 558: C. F. v. Graefe, lihinojylastik ; FlllCKE, in v. Graefe und V. Waltiieu’S Journal, Bd. tl2, p. 45G; FriEDUERG, Chirurgische KliniJc, Jena, 1855; Malgaigne, Mid. operat., 1843, p. 421 ; Erichsex, Science ami Art of Surgery, p. G70; Albucasis, Chirurgia, Lib. H, Cap. 13 et 14; ThevexiX, Oeuvres, Chap. 99, ICO, Paris, 1G59; PLAINER, InsUtutioncs chirurg., Lips., 1745, Par. 580; 'TT'IXTOR, Ueber Chciloidastilc, Bd. XXI, Ileft 5 u. 6, p. 49G; CramptoX, Essay om entropium, London, 1815; DELI’ECII, Chirurgie clinique, Tom. H, p. 587; Caurox DU VlLLARD, Jiestauratio7is des 2 )anpiires, in Gazette dcs hopitaux, 163G; Sa^:S0N, Journal universelle et hebdomadaire, No. 1G2, u. 1G4, Nov. 1833; BUST, Ilandbuch der Chirurgie, Bd. IV, p. 575; Ciiopart, Anaplastie des levres, des Jones ft des paupidres, Paris, 1841, p. CO; Velpeau, Lanc.fran^, gaz. d'Hdpit., 13, Aout, 1840 ; MaisoXABE, Clinique sur Ics dijj'ormitis dans Vespece humaine, Paris, 1834, Tom. II, ju ICO ; BECK, Ilandbuch der Augenheilkunde, Heidelberg, 1823; DeSMARRKS, Annales d' Oculist, Oct. 1843; and also the works of Syme, Lakciier, FOLLIX, PARTRIDGE, NtLATOX, Earle, Coote, SliE, I\Iuller, Teele, Paxcoast, Prince, B. Brown, J. M. Warren, Ollier, Laxgenbrck, Buchanan, Cooper, Gensoul, Ciielius, Dzondy, J.veger (Vienna), Baum, Lisfuanc, Dupuytrex, Koux, Lallemand. Mouleau, Tiiomain, Hutchinson, Davies, SvMic, T’vRRicL, Liston, Hoefft, Pirogoff, Dvbeck, and Clot-Bev. Sect. III.! CONCLUDING OBSERVATIONS. 381 geon has contributed to the Museum a number of casts and photographs illustrating the re- markable operations that he has accomplished for the repair of deformities from shot inju- ries of the face, with references to the instructive descriptions that he has published in the journals, of the steps of these difficult and ingenious surgical achievements. In the Third Surgical Volume will be found, in Plate XXXVIII, a representation of an interesting example of blepharoplasty after shot injury.] Concluding Observations on Wounds and Injuries of the Face. — In the pre- ceding pages abstracts of individual cases of the different groups of this category have been detailed almost without commentary. It remains to examine numerically and more compre- hensively the regional distribution of the various injuries, and to add such remarks upon the several subdivisions as are suggested by the reports. In Tables XII and XIII, statements of the results of gunshot fractures and flesh wounds of the face are presented. Table XIV contains a summary of operations after wounds of the face, and table XV gives a recapitulation of the aggregate results of injuries of the face from whatever cause, — incised, or punctured, or lacerated, or contused, or gun- shot, — with or without fracture, that appeared on the returns during the War : Table XII. Table of Three Thousand Three Hundred and Twelve Cases of Gunshot Fractures of the Bones of the Face. REGION. Cases. Died. Discharged. Dufy. Unknown. Inferior maxilla 1, G07 121 779 550 157 Superior maxilla 555 42 247 228 38 Both ma.xilla; 1.57 13 8G 46 12 Maxilla ; not stated 2G0 33 96 80 51 Malar. - 218 14 95 89 20 Nasal - 93 26 53 14 • Palate 17 7 7 3 Several bones implicated 405 117 152 101 35 Aggregates 3,312 340 1, 488 1, 154 330 It appears fiom Table XII that of the two thousand nine hundred and eighty-two cases in which the results were ascertained, 11.4 per cent, died, 49.9 per cent, were discharged, and 38.7 per cent, went to duty. It has not been practicable to learn how many of the one thousand four hundred and eighty-eight discharged men were pensioned ; but we can judge fairly of the proportion by analyzing the one hundred and thirty-eight abstracts in Section II, of this Chapter, and find from the record of the eighty-one patients who recovered, that forty-nine, or 60.5 per cent., 'were pensioned. Hence we are forced to the conclusion that gunshot fractures of the bones of the face are, when we consider large averages, graver than writers on military surgery have, heretofore, admitted ; for 382 AVOUNDS AND INJURIES OF THE FACE. [Chap. II. beside the considerable rate of mortality in these three thousand cases, a large proportion of those who recovered were disabled, and invalided. The lodgment of balls in the maxillary sinuses, in the ethmoidal and sphenoidal cells, and the consequent protracted suppuration, necrosis, and exfoliation, evulsion of teeth with inability to masticate, and frequently with the persistent discharge of foul pus, and unwholesome broken-down tissues into the throat ; secondary hiemorrhages from vessels not readily secured, and secondary inflammations extending to the brain ; these are among the causes which bring the mor- tality rate of wounds of the face to within nearly a fifth of that of wounds of the head. Table XIII. Table of Four Thousand Nine Hundred and Fourteen Cases of Gunshot Wounds of the Face, without known Fracture. INJUKIES. Cases. Died. Duty. V. 11. C. Exchanged. Discharged. Deserted. Furloughed. Unknown. Flesh Wounds of the Face.. . 4,914 58 , 2,147 15G 93 780 187 343 1, 150 Of the above 4,914 cases, seventeen were complicated with erysipelas, three with gangrene, seven with pyaemia, and nine with secondary haemorrhage. In two cases there was neuralgia ;■ in two, necrosis ; in four, paralysis ; and in one, concussion. In five cases, the hearing was impaired, and one resulted in aphonia. The missile is reported to have lodged, and without record of its being removed, in twenty-two cases ; and the fact that it was extracted is recorded in sixteen cases. Of the fifty-eight fatal cases, five died of erysipelas, two of gangrene, six of pyaemia, seven of secondary haemorrhage, seven of pneumonia, eight of chronic diarrhoea, four of t}q)hoid fever, three of small-pox, and one each of congestive fever, enteric fever, irrita- tive fever, diphtheria, ascites, and spasm of the glottis, and ten from causes not stated. Table XIV. Nature and Results of Nine Thousand Eight Hundred and Fifteen Injuries of the Face from all Causes. INJURIES. Cases. Duty. Discharged. Died. Unknown. Sabre and Bayonet wounds 64 40 15 2 7 Fractures of the bones of the face from various causes 64 37 17 3 7 Injuries of the face from miscellaneous causes 271 167 83 3 18 Gunshot flesh wounds of the face 4, 911 2, 396 1, 310 58 1, 150 Gunshot wounds of the orbital region 1, 190 379 679 . 64 68 Gunshot fractures of the bones of the face 3, 312 1, 1.54 1,488 340 330 Aggregates 9,815 4,173 3, C92 470 1, 580 In the eight thousand two hundred and thirty-five cases in whicli the i-esults were determined, the mortality rate was 5.7. But it was probable that this I’atio would be much diminished if the termination of the remaining one thousand live hundred and Skct. III.] RESULTS OF OPERATIONS. 383 eighty cases could be traced. In the British army in the Crimea,'" fractures of the face numbered one hundred and seven, and flesh wounds four hundred and twenty-six, a total of five hundred and thirty-three, or 7.4 of the entire number of wounds, and the mortality rate was but 2.6. But, in the British return, the proportion of wounds penetrating or perforating the bony structures was but 20.1 per cent, of the face injuries, whereas in Table XIV, the proportion of fractures is 33.5. In reporting on the casualties of the French Crimean Army, M. Chenuf records one thousand four hundred and fourteen injuries of the face from all causes, with a mortalit)^ of one hundred and eighty-four, or 13 per cent. In his statistics of the Italian war of 1859, the same author J tabulates nine hundred and fifty-five cases of face injuries, with one hundred and fourteen deaths, a mortality rate of 11.9. The next table exhibits the number of operations performed after, wounds of the face : Table XV. Table of Six TTundred and Seventy-one Ofteraiions after Wounds of the Faee. OPERATIONS. Cases. Hied. Discharged. Duty. Unknown. Excision of jtortions of the inferior maxilla 81 8 58 9 6 Excision of portions of the superior maxilla 13 3 8 2 Excision maxilla, not specified 3 3 Excision, malar 7 2 4 1 Excision, several bones 7 1 4 1 1 Removal of bone 268 16 136 98 18 Extraction of ball 192 9 92 65 26 Ligation of common ctirotid 53 38 11 3 1 Ligation of external carotid 6 2 2 1 1 Ligation of common and external carotid 2 1 1 Ligation of facial 5 1 1 o 1 Ligation of lingual 1 1 Ligation of internal jugular vein 1 1 Ligation of branch of superior thyroid 1 1 Plastic operations 32 27 4 1 Aggi-cgatcs 672 81 349 186 56 Having furnished the statistical evidence, verified as carefully as has been practicable, we can now consider the conclusions to be derived therefrom relative to flesh wounds and fractures and operations in this region. * Medical and Surgical Ilistory of the British army, which served in the Crimea, during the war against Russia, in the years 1854, 1855, 1856. London, 1858. Vol. II, p. 304. t Rapport an Cnnseil de Santi des Armies sur les Risultats du Service Midico-Chirurgical aux Amhulances dc Crimie et aux Ildpitaux Militaircs Francis en T nrquie pemlant la Campagne d' Orient cn 18.54, 18.5.5, 18.56. I*!ir .1. C. C'HEMJ, I). M., IMedecin Princip.il, liibliothecaire do i LcoIc Lniiorialo de Sledecinc Jlilitairo, (llTicicr de la L6gion d'llonneur, etc. Paris: Victor .Masson et Fils, 1805. (Juarto, p. 14,5. ; Statistiqne Meiico-Chirurgicale de la Campagne d'Rali’e en 1850 e! 18J0. Par le Ur. J. C. ClIE.NU, M6decin Principal d'Armdc cu rotraite, etc., etc. Paris; 1869, T. II, 447. 384 WOUNDS AND INJUEIES OF THE FACE. [Chap. II, Wounds of the Ear. — The abstracts of face injuries selected comprise few of the ear. The wounds of the auricle were either infrequent or else regarded as of insufficient importance to be particularized. In the few cases in which any details were given, where the yellow cartilage and ligaments of the pinna were torn by musket halls or divided by sword-cuts, the parts were plastered together, sutures being used sometimes, and the dressing was completed by lint compresses, with cerate or warm fomentations, and a roller bandage. The results were generally unfavorable, the injured tissues, in a few days, sloughing away. Nearly all of the reported injuries of the middle and internal ear have been considered in connection with the head injuries. One of the most interesting is that recorded on p. 175 [ante), of Major Simms, who, at the Wilderness, was struck by a conoidal ball, which buried itself in the petrous bone. Seven years subsequently, the Pension Board, in New York, furnished the following additional particulars in the case : “ Examining Board, New York, March 22d, 1871. Report ball entered petrous portion of left temporal bone. There is now an opening one-half inch in diameter, two and one-half inches in depth, forward and inward, and connecting with the ear. The tympanum has been destroj'ed. The symptoms of cerebro-spinal lesion are complete. Paralysis and partial atrophy of muscles supplied by the left facial nerve. Complete deafness in the left ear, partial blindness in the left eye, and anaesthesia of the integument of the left side of the head and face. There is also partial paralysis of the right arm and leg, but no implication of sensation in those parts; certain muscles in the right leg have become shortened, producing deformity of the right foot. The ophthalmoscope reveals degeneration of the left optic disc. These .symptoms are due to a circumscx’ibed inflammation of the base of the brain, results of the above-described wound. The disability will steadily progress, and, in time, destroy his life. Disability total, second grade ($20 per month). Pemianent, and will increase ; he has been in his present condition since January, 1866. In February, 1872, I examined this officer, who then had partial right hemiplegia, with facial paralysis on the left side. There was a deep cavity communicating with the left petrous bone, the orifice closed by a rubber obturator, devised by one of the ingenious aurists of Philadelphia or New York. Puriform discharge and exfoliation of the can- cellous structure of the temporal persisted, and the diagnosis and prognosis of the examining board was reluctantly vffiified. Baron Larrey^ and Dr. Hennen,® have sanctioned the belief that the auricle may be nearly torn off, and yet be made to re-unite. Dr. Nathan E. Smith holds the same opinion,^ and describes the proper mode of promoting adhesion by using sutures of the integument on either side, sparing the cartilage, a precept disregarded by Leschevin^ and Verduc,® but inculcated by the ancients. Pard and Hildanus and other authors of the time when sabre-cuts of the external ear were common, and ablation of the ear as a punishment not infrequent, recite instances of adhesion of the auricle after its complete detachment, and give minute instructions as to dressing such wounds. Such instances are not recorded in the returns we are considering. The rule to cleanse, replace, and keep in apposition by sutures and adhesive plasters all lacerated portions of the ears, nose or integuments of the face is as absolute in military as in civil surgery, and, as Mr. Coote observes,* *’ some unpromising cases terminate with comparatively slight deformity. After all, the loss of the external ear in man, however unsightly, impairs the hearing but little. Seven instances are found in the records where the auricle was carried away by large projectiles, — either cannon shot, or shell-fragments, or grape, and two cases where great ■ D. J. Laubev, Clin. Cliir., ed. cit. T. V, p. 61, and Mim. de Ghir. Mil. 1817, T. IV, p. 239. * JOHN HENNEN. Op. cit. 3d cd., p. 353. ^ .See his Supplement to a Translation of Saissy's Work on Diseases of the External Ear. Baltimore, 1839, p. 206. ■* Leschevin, Mem. pour les Prix de VAcad. de Chir. Paris, 1819. T. IV, p. 85. ® VekduC. Ahrcge de la Chir. de Guy de Chauliac. Paris, 1740. ® Holmes. Syst. of Surg. 2dcd. Vol. II. p. 420. Sect. III.] REVIEW, WOUNDS OF THE ORBITAL REGION. 385 mutilation of the external ear was produced by musket balls. Of these nine patients, six were returned to duty, with the sense of hearing believed to be as acute as ever, and as the three who were discharged cannot be traced on the pension rolls, it is probable that their disabilities were not serious.'^ ,This series of observations should set at rest the question — if it remain a question in the mind of any experienced military surgeon or officer of ordnance— of the “windage” of balls. Rupture of the membrane of the tympanum from propinquity to artillery fire was frequent. The precautions enjoined by the gunners in the navy, in serving heavy ordnance, were not always observed in tlie army. The proportion of cases of deafness among the officers of the artillery arm, as well as among the cannoniers, has been, since the war, a frequent subject of remark. Wounds of the Orbital Region. — Many examples of injuries of the superciliary region and of the frontal sinuses have been cited in the chapter on wounds of the head, and on page 325, and succeeding pages, are grouped thirty-nine cases of wounds of the malar and infraorbital regions, involving both eyes. These are followed by a long series in which a single eye or its orbit was implicated. The sad series of destruction of both eyes by small projectiles gave a mortality-rate of 27.8, only. In addition to the two instances of recovery, after balls had passed from side to side behind the orbital foramina, dividing, no doubt, the optic nerves, was that of a general officer, wounded at Gettysburg, whose case was not reported in detail. There was less of suppuration and necrosis in these three than in much less formidable cases, and the cicatrices remained firm and sound, with no consecutive disease of the surrounding tissues, although so many of importance were implicated. The returns furnish many abstracts that might greatly interest students of ophthalmology could they be reported with minuteness ; but the duties of the reporters forbade them to give those precise details which give value to such observations. Of gunshot wounds of a single eye, there were twenty-six, in which it was requisite to extract balls or fragments of bone, and it was found well to interfere unhesitatingly when the lodgment of foreign bodies in the orbit was suspected. Extirpation of the globe was called for in two instances. A loss of the senses of smelling or hearing was observed in six of the cases of recovery selected for publication. There was a special hospital for the treatment of wounds and diseases of the eye established during the war, under the charge * Consult fiirther on the effect on hearing of loss of the auricle, ‘NVErFEii, Ueher das schiucre Gehor^ Leipzig, 1794, p. 19; J. F. ISIeckel, Ilandbtich der Pathologischen Anatomic, IL I, p. 400, Leipzig, 1812; Fhitelli, Orteschi Giorn. di Med, T. Ill, p. 60; Obeuteuffeu in Stark's Neues Archiv. B. II, p. 638, and Jlr. Darwin, Descent of Man, Vol. I, p. 12; Itard, Traite de$ Maladies de V Oreille et de V Audition, Paris, 1842, says that “everj'thing combines to show that the auricle is absolutely useless in man; t^jat the hearing is not altered when it is removed, I have had occasion to assure myself most positively.” Valsalva {De aure Humana tractatus, Bologne, 1703) and Haller {Disp^dationes anatomiaie) and Leschevin {Prix dc V Acad., T. IV, p. 87) express an opposite opinion ; but adduce no evidence in support of their assertions. WiLDE, On Aural Surgery {Am. ed., 1855, p. 104) ; Kramer, Handhuch der OhrenheilJcunde, Berlin, 1867 ; I’lLCHER, Treatise on the Ear {Am. ed., Phila., 1843, p. 41), say nothing to controvert Itanl's doctrine. TOYNBEE {Diseases of the Ear, London, 1868, p. 12) remarks that in the recorded cases of diminished hearing from wounds of the auricle alone, no accurate acoustic tests were employed, and he gives a carefully obser\’ed case of a sailor, whose external car was bitten off without any impair- ment of hearing. Consult further on this subject: WRIGHT, Varieties of Deafness, London, 1829, p. 8; Erhard, On Examination of the Ear with lieference to Soldiers and Medico Legal Questions, translated from Wien. Wochenschrift, 1864, pp. 730, 761, and Brauchhare Jlorohre, Berl. Klin. Wochensehrift ; THOMSON, A., Edinburgh Jour, of Med. Sci., 1847; MOOS, Ueher das Subjective ITdren wirklicher musikalischer Tone, Virchow's Archiv., XXXIX, 2, p. 280; Agnew, C. U., Sinus through Mastoid from Old Otitis Media, Transactions of the American Otological Society, Boston, 1870; LUCJE, Ueher eine Neue-Methode zur Untersuchung des Geh'ororgans zu Physiologischen and Diagnostichen Zweeken, in Arch.fiir Ohrenheilkunde. Ill, 2, No. 3, p. 186; IlOOSA, D. B., in Trans. Am. Otol. Society, Boston, 1870, and Am. Jour. Med. Sci., April, 1871 ; Pagenstecher, On Trephining the Mastoid Process and Petroxis Bone, Arch.f. Klin. Chir., IV, S- 523, 1864; COLLES, W., Dublin Quart. Jour, of Med., No. 99, p. 32; Follin, Gaz. des Hop., 1864, p. 4; Eustachius, B., Tab. Anatomicx Cur. Lancisii, Amsterdam, 1722; CURTIS, Present State of Aural Surgery, etc., 2d ed. London, 1841; Harvey, The Ear in Health and Disease, with Practical Remarks on the Prevention and Treatment of Deafness, London, 1865; Turnhull, Clinical Manual of Diseases of the Ear, Phila., 1872; A. B^:uard, Diet, dc Med. ou Rep. Gin. des Sci. Mid. 2“® cd. Paris, 1840, T. XXII. p. 3.50; Cassebohm, Dissertationes de aure interna, Franefort, 1730; C..VSSEUIUS, De vocis auditiisqne organis historia anaiomica, Fcrraria, 1600-01; COTUNNIUS, De aquxductibus auris humanx internx, Neapol., 1760 ; TrOltsch, Diseases of the Ear, their Diagnosis and Treatment, New York, 1 964 ; GRUBjiu, Lehrbuch der Ohrenheilkunde, Wien, 1870 ; Fano, Ti'aiU ilimentaire de Chirurgie, Paris, 1869, T. I, p. 737, devotes a large sub-chapter to wounds of the membrane of the drum; Neill, A Report upon Deafness, Liverpool, 1840. 49 WOUNDS AND INJURIES OF THE FACE. [CiiAr. II, 38() of Surgeon Joseph H. Hildrctli, U. S. V., and special wards were assigned for this purpose in several of the larger general hospitals.* * An hospital steward, long on duty in this office, wlio lost an eye at Gettysburg, has observed, with natural interest, the remote eflects of the destruction of the globe of the eye by musket or pistol balls, in the numer- ous pensioners who visit the Army Medical Museum. In all who wore glass eyes, there was a shrinkage of the soft tissues of the orbit, which called for the replacement of the artificial eye by a larger disk. In about half of the cases, the enamel substitute followed the movements of the globe of the remaining eye. It was found unwise to wear the artificial eye more than eight of the twenty-four hours of the day, and the uninjured eye had to be treated tenderly, becoming irritated readily from slight causes. There was a case of a punctured wound of the eye, which came under my observation, November, 1861, that of Corporal Levi Brizzee, Co. 0, 27th Massachusetts Volunteers. Entering a small “ wedge tent,” from the bright light outside, he walked upon a stack of muskets, and the point of a bayonet entered the lower part of the right cornea, producing a laceration of the iris, with protrusion. He was brought immediately to the regimental hospital, a few yards distant. The anterior chamber was filled with blood, and the condition of the interior of the eye could, therefore, not be discerned. With a probe, I raised the corneal flap, and replaced the prolapsed iris, dressing as after an operation for extraction of cataract, — borrowing an hair pillow, to elevate the head, from the neighboring general hospital. Without other treatment than a severely restricted diet this man recovered, and his vision was unimpaired. On the third day, I removed the occlusive dressing, and found the anterior chamber free from blood, and the cicatrization of the iris progressing favorably. In three weeks the patient returned to duty with less opacity of the cornea than is usually seen after cataract operations. Subsequently, I frequently met him on the field, and was astonished at the absence of even the loss of the power of accommodation in the injured eye. He told me that he always aimed with that eye. There was slight distortion of the pupil, and a leucomatous streak at the outer margin of the cornea; but I could not discover any impairment of vision. I endeavored to trace the history of this remarkable injury; but the man was made prisoner in the action Drury’s Bluff, May 16th, 1864, and, escaping from the military prison at Macon, Georgia, rejoined his regiment in North Carolina, and I did not see him again. He died of pernicious intermittent fever, at his home in Massachu- setts, wliile on i'urlough, April 15th, 1865. In searching the records, I have not found examples of wounds of the lachrymal glands distinct from general destruction of the contents of the orbit. Those reported by Bavaton^ and Larrey® appear to remain the only recorded instances. Wounds of the Nose.— The few cases reported in detail of wounds of the nasal region were those in which some attempt at reparation or restoration had been made. On page 322 several cases of sabre cuts of the nose are enumerated, and illustrations of gunshot. wounds of the nq^e are given on page 358. In incised and lacerated wounds of * The ophthalmoscope was not used in the field hospitals of the Union or Southern armies, so far as ca.i be leanied. But in the recent Prussian- French War, we learn from' Dr. L. VASLlx's G lides siir les Plains par Armes a Feu, Paris, 1872, p. 203, ct se.q., that Dr. Galogowski was able to determine the existence of subchoroidean elTusions and of lacerations of the choroid by contrecoup. Tliese refinements, like that of detecting- a cheiTy-stono in the cesopliagus by percussion, are not of practical utility. t Being shot through the di'sccnding colon and left popliteal space as well, and having, alter eight years, a fistula in the lumbar region and false anchylosis of the knee. * Op. cit., p. 17.5. Clin. C/iir., T. 3, 31)6. I’eniarkable examples of foreign bodies lodged for many years in the orbit, are recorded hy Dr. Gai.kzOWsxi, Traite dc Maladies des Feax, Paris, 1872, i». 81.0, and by 1\I. DEMAKQUAV, McnK sur les (^orjis etrav/j. arretes dans VOrbile. l/Union M^d. 1851), pp. 82. 123. Sect. III.] REVIEW, WOUNDS OF THE CHEEK. 387 the cartilaginous portion of tlie nose the parts were secured in position by adhesive strips, and by placing in the nostrils bits of gum catheter plugged about with sponge or lint, to preserve, as much as practicable, the proper configuration of the organ, and to avert the contraction of the nasal passages and depression of the nose, which give, in some instances, such an unpleasant resemblance to the results of tertiary syphilis.^' In these lamentable cases, surgery has little aid to aflford. As has been seen in Section III [ante p. 368), some- thing may be sometimes accomplished by plastic procedures. Again, the deformity may be masked by an artificial nose of wax or gutta percha.f When the nasal and spongy bones were destroyed the condition of the sufferers was yet more cruel. In all of the cases that I have examined or enquired into, there was no cessation in gradual exfoliation and foetid discharge into the nares, even after six or eight 3 mars. The patients thus suffered ill-health because of the local lesions, and mental distress from feeling that their injuries rendered them repulsive. Such Cases appeal to our warmest commiseration. Wounds of the Cheek. — Examples of punctured wounds by the bayonet, and of incised wounds by the sabre have been cited on page 323. The latter presented a frightful appearance sometimes ; but usually healed readily under the judicious use of adhesive strips and sutures, with support from bandages. The cheeks were often badly torn by gun- shot projectiles, and ugly cicatrices were left ; but in the majority of cases the missiles pene- trated or perforated the buccal cavity, often implicating the teeth or jaws. Of wounds in- volving the soft parts only, the most interesting were those in which the division of the parotid duct resulted in salivary fistula. Dr. John Thomson [Report after Waterloo), met several cases of this sort, -and regarded them as very difficult to cure, and generally incur- able ; but I had one case under my immediate care, of an incised wound of the anterior part of the right duct of Steno, in which the fistula closed in about eight weeks. The treatment consisted in introducing a probe daily into the orifice of the duct, opposite the second molar, and occasionally cauterizing the external wound and applying constantly an occlusive dressing with collodion. In this instance, the continuity of the duct was pre- served, and, after recovery, the saliva might be seen to trickle from the buccal orifice of the duct. Other successful cases are reported, two of which are noted on page 380. Some valuable observations on this subject are to be found in the Memoirs of the French Acad- emy of Surgery.J Many instances are reported where wounds of the portio dura ol' the seventh pair, or branches of the fifth pair, caused various paralyses or nervous twitchings, or tics in the muscles of the face. Several examples will be found in the preceding })ages, and others are detailed at length in the dissertation already alluded to, on gunshot wounds and injuries of the nerves, by Drs. Mitchell, Morehouse, and Keen. These careful observa- tions, made at the military hospital at Christian Street, Philadelphia, illustrate the utility of electric currents in the treatment of such cases, besides affording interesting physiologi- cal and clinical studies. * There have been not a few instances nf discharged soldiers who liave reliuquislied humble positions under Government, and of otfteers who have gone into retirement on account of tlieir sensitiveness regarding disfigurements after wounds cf the nose, that were ascribed by the ignorant an\c^lfArFM)KN'llC (Dn Vain. pirticuL), ML’.n’.NICX.S (Prar. (Jhiranj., Lib. 2, c. lb), UooMiL’is, PlCVUrUK, Vaxdkiiwikl ( Ohn. rar., 'P. 2 , .MOlt(;Ar.\T < Advrrs. Anatom. VI), IvF.3XIF.ll Die Gu \AF and VK’l’MIHVr.-X'. and many otliers important facts respecting tins form of injury. See also I.KC.OPFsr. 1. v. p. 382. 388 WOUNDS AND INJURIES OF THE FACE. [Chap. II, It is well known ■ that Larrey^ recommended, in accordance with the precepts of Desault,^ to unite all gunshot wounds of the soft parts of the face by sutures, having first pared or “refreshed” the contused borders. Surgeon J. J. Chisolm,^ P. A. C. S., sought to generalize this method, and a circular letter was issued by the Confederate Surgeon Gen- eral, calling for reports on the subject. Surgeon Middleton Michel, P. A. C. S., published^ a paper on the subject, with cases designed to prove the efficacy of the method. I will here only say briefly, that the evidence adduced was inconclusive, and that I fully agree with M. Legouest,® that Larrey’s advice should not be followed in gunshot wounds of the face, since the slighter cases, and even those in which the cheeks are perforated, or the lips divided, generally healed readily, while the extended lacerations were commonly followed by swelling and elimination of the mortified parts ; and by regulating such wounds by the knife, there was great liability of sacrificing more tissue than nature would have done. Wounds of the Upper Jaw. — The returns of these injuries presented a larger pro- portionate fatality than the observations of European surgeons would have led us to an- ticipate. Our reports indicated that the patients who escaped the immediate dangers of hsemorrhage, either primary or consecutive, had often to undergo such complications as erysipelas and pysemia ; while copious and protracted suppurations and the accidents per- taining to the ingestion of decomposed secretions into the digestive organs were other perils to be encountered. Dr. Chisolm [op. cit. p. 502) in the last edition of his manual for the use of the Confederate surgeons, published in the third year of the war, shares the opinions of Dr. Stromeyer [op. cit. p. 36) and of Matthew [loc. cit. p. 305), and regards the accidents which follow, even very severe injuries of the facial bones, as comparatively slight. But the facts embodied in Table XIV compel one to dissent from this conclusion and to adopt rather the opinion of Guthrie [op. cit. p. 524) that such wounds are often followed by “ much suffering and by permanent inconvenience.” In consulting the returns of the Pension Office, and in communicating with medical officers of extended experience, few examples of fair healing of gunshot wounds of the spongy bones forming the walls of the nasal cavi- ties have been noted, though many pensioners with such injuries have now been upon the rolls or under observation for six or eight years since the recejition of their injuries, — and to indicate how long such wounds may remain unhealed, I will here cite the case of a pen- sioner of the war of 1812, for which I am indebted to Dr. A. L. Lowell, of the Pension Bureau : Case — Private Noali Austin, of Captain Brown’s Co., New York State Militia {Pension Claim No. 1700), was enlisted August oOtli, 1812, and was wounded at Queenstown on October 13th, 1812, and died on September 12th, 1870; the following are copies of the various surgical certificates in the case; 1st: “ Gunshot wound received at the battle of Queenstown. A canister shot entered the face one and a half inches to the left of the nose, and still remains lodged in the bones of the face. There is an opening in the hard palate three-fourths of an inch in diameter, and there is a discharge through both wounds, but principally through the nose. His speech is affected and his general health is impaired. The disability is total.” 2d : “A canister shot entered the face between the nose and the left cheek. The ball now remains in the cavity of the cheek, and still remains lodged in superior maxillary bones, from which constantly issues a foetid discharge, and it totally disqualifies him for manual labor.” 2Cl, filed October 9t/i, 1831 : “External wound a little above alae of nose, left side, on a line falling from inner canthus of left eye. The shot entered obliquely and probably lodged under the left malar bone. From a fistulous opening, there is a constant discharge. The presence of the ball produces irritation and afiects the health, so as to disqualify from manual labor.” 4th, filed Septemher Zd, 1839 : “ Gunshot wound of the head ; ball still remains lodged in the head, causing constant ‘ Clin. Chir., T. II, p. 3. Dicsault, aSuvres Chirurg., 3d cd., Paris, 1813, T. II. 3 ClUSOLM, op. cit. * liichmond Med. Jour., 18GG, Vol. I, p. 448. 5 Op. cit. p. 385. Sect. III.] EEVIEW, WOUNDS OF THE UPPER JAW. 389 discharge from the nostrils. The shot has changed position since 1833. Disability increased.” 5th, fikd March 2Gih, 1850 ; “ Canister shot in left cheek; constant pain and intense headache when stooping, and totally unfitting him for manual labor.” 6th, filed September 12th, 1870: “The pensioner died from the effects of a gunshot wound of the head and face. For many years said wound kept up a constant discharge, and when he died the discharge had greatly increased, and just before he died, the ball passed into his mouth and was taken out by him, after it had destroyed the bony structures where it had been lodged. The immediate cause of death was pyaemia.” Balls lodged in ttie facial bones are, however, sometimes eliminated by the efforts of nature, as in the case of Private Williams, 5th Vermont, noted on page 342. The missile, a musket ball of ragged shape, had lain upon the left palatine bone from May 6th, 1864, until May 22d, 1868, when, according to the Manchester Journal, the patient, being aroused from his sleep by a sense of suffocation, with great pain extracted the projectile with his fingers through the soft palate. Yet the removal of the foreign body did not effect a cure, and the pensioner is still on the rolls. To the many illustrations already adduced, may be added that of General Alexander Asboth, who was shot September, .1864, by a musket ball, at Marianna, Florida, the missile passing through the left antrum of Highmore, and lodging upon the palatine bone. The external wound healed ; but there was profused suppuration and interminable exfoliation through the posterior nares, and the general, already enfeebled by the effects of a gunshot fracture of the humerus, received at Pea Pidge, of a flesh-wound of the ‘thigh, and several sabre wounds of the face, was steadily losing strength. After he had been a year or more under treatment, he visited Washington. There was a profuse purulent discharge into the fauces, and frequent exfoliations. The ball was readily detected by passing the left index finger above the arch of the soft palate. Though he had resolved to submit to an extraction of the missile, his duties in connection with the mission to the Argentine Republic, with which he had been charged, were so urgent that he sailed without under- going the operation. Suppuration and exfoliation continued, and the general died at Buenos Ayres, three years afterwards, from the effects of this wound. These instances, with the figures presented in the tables, may suffice to controvert the assertions of those military surgeons who regard gunshot wounds of the maxillary sinuses as comparatively trifling. The more detailed abstracts reported indicate that in the treatment of wounds of the upper jaw, the practice of experienced surgeons, employed in the war, generally conformed to those simple lessons taught by the later preceding’ European campaigns, and confirmed by what we can learn of the surgical results of the wars of 1866 and 1870. Dr. Chis- olm [1. c., p. 304) informs us of the usual course pursued by the Confederate medical officers : “ Unless the fragments are either completely detached or but slightly adflerent, they should not be taken away, but should be replaced with care — as, in time, consolidation may take place, and very little permanent deformity will be left. Should some of these frag- ments die, they will be found loose, often as early as the sixth or eighth day, and should be removed. The cold-water dressings, with an occasional dose of salts to relieve the excessive swelling, is the only medication required. The wound in the face, after a careful adjustment of the movable fragments, should be -closed with adhesive plaster, and, with the use of cold-water dressings for a few days, the case is left pretty much to nature.” To cleanse the wound, to remove detached fragments of bone^ to replace and adjust undetached fragments, to suppress hsemorrhago ; then to bring tlie soft parts as nearly in apposition as j)racticable, connecting them with adhesive straps, and dressing lightly with 390 WOUNDS AND INJURIES OF THE B'ACE, [ClIAI>. II, compresses clipped in cold lotions, and supported by a bandage — such was the simple routine commonly observed by the Union surgeons, and with fair results usually, thougli much deformity was left in many cases, and tlie proportion of fatal results was not incon- siderable. ]\[r. Blenkins (/. c. p. 822) confirms the observation of Guthrie that, where the lachrymal bones or sac are wounded, the tears usually continue through life to overflow ; — and Dr. AVilliamson [oj). cit. p. 65) describing the invalided men from the Indian mutiny, speaks of the serious nature of gunshot wounds of the face and of the fediousness of their cure, — of the caries and necrosis and “profuse and very foetid suppurative discharge”^ that followed such injuries. Matthew, in his Crimean surgical report, expresses the belief that extensive necrosis rarely takes place in wounds of the facial bones ; but it must be borne in mind that he had not the opportunity of following the ulterior histories of the cases he reports. In the footnote' is appended his view regarding the treatment of detached bone fragments and teeth. j\Ir. klatthow cites a case of grave secondary bleeidng, in whicli the ap|)lication of perchloride of iron proved successful ; and Dr. Chisolm observes, in this connection, that “the iron styptic will control the most annoying haemorrhage.” The persulphate of iron in powder, and the perchloride in solution, were largely employed by the surgeons of the Union Army in haemorrhages, both secondary and primary. These salts were placed in every hospital knapsack and in every hospital. Little evidence is adduced of their utility, though the suffering they caused to the patients is jiainfully conspicuous. In wounds of the upper jaws especially, they increased the inflammatory phenomena, and, moreover, converted the tissues into a blackened mass, in which the relations of parts could not be distinguished, and bleeding vessels could be properly secured l)y ligature only with the greatest difiiculty. Such is my intense aversion to the employ- ment of these sty})tics that I am not, on this point, an impartial judge, and will prefer to cite a very competent authority. Dr. Garretson “ Monsel’s solutions, so warmly lauded for their styjkic qualities, have exhibited to me more ill results than I have ever met with from any dozen other articles. If used at all, I tliink the bleeding points sbould be alone touched ; but of one thing any one using them may bo assured : if the application does not control the heemorrhage instantly and permanently, he will have increased his trouble manifold.” Wounds of the Lower Jaw. — Guthrie remarks {1. c. p. 525) that these injuries “ are perliaps more common, and are certainly more troublesome than those of the upper.” The records we are considering indicate that the frequency of gunshot fractures of the lower maxilla is thrice that of similar injuries of the upper jaw-bones. Dupuytren declares {1. c. T. VI, p. 258) that the gunshot injuries of the lower jaw are far the most dangerous. The records show that in an aggregate of more tlian two thousand cases (see Tadle Xll, }). 381) the ratio of mortality was nearly equal in the two classes of injuries : 8.1 per cent, for the ujiper, and 8.3 for the lower maxilla.'* ^ 8ee rreiiaratiou 2955 of the Netley Museum. 2 •‘T'here is. indeed, no great object beyond, perliaps, the present comfort of tlie patient to be attained in removing either fragments of bone or loosened teeth in the great majority of instances. If they die, tliey become loose, and are readily lifted away without trouble to the surgeon, and but little jiain to the patient. This observation is specially applicable to fractures of the lower jaw. Surgeons in this [the Urimean] war liave seen so many eases of badly-fractured instances of this hind unite, and that with a very small amount cf deformity, that men of experience arc now excessively charj’ of removing any portion of this bone, unless it has become dead, (T the fnigment is so situated as to interfere considerably with the adjustment of the rtmiainder, or the bone so nuudi comminuted as to give no probable hojie of its becoming consolidati'd, or so sliari'ly angular as to threaten further injury to the soft jiarts, or to intcrferi' materially with their adjustment.” Op. cit., Vol. II. p, 305. ^ ( i AKKL'LSON, .Iamls 10. A ITvatise on lh(i Diseases and Surgery of tin* Mouth, Jaws, and Associate Parts. Phihnleljfliia, 1869, p. 474. Dupuytren fell into amflher error by reasoning deductively, and teaching that on account of the great density and hardness (;f the inferior maxilla, the resistance opposed by it, a .shock to the cerebrum was often produced by the impact of balls, a species of cmitrecoup, causing cerebral commotion. Ilis disciiilcs, II. LaiTC}' and l.egouest. “find this an hard doctrine." There is nothing in the records we are examining to sanction it. Sect. III.] KEVIEW, WOUNDS OF THE LOWEK JAW. 391 111 the Confederate armies, some form of inter-dental splint was often employed in gunshot fractures of the lower jaw. An apparatus devised and successfully used in many unpromising cases hy Dr. J. B. Bean, a dentist of Atlanta, Georgia, is praised liighly hy many of the Southern surgeons,^ and forty or more examples of its useful apjilication have been published. According to Dr. Chisolm [1. c. p. 305) the usual method of treat- ing gunshot fractures of the lower jaw was that described in the footnote.^ As ]\Ialgaigne has remarked, in treating of fractures of the lower jaw, the '^fixation des denis ” dates from the time of Hippocrates ; but every writer on minor surgery has his pet fixture. The evidence of the utility of Dr. Bean’s apparatus, in cases in which its application was supervised by himself, is conclusive. Surgeon Philip S. AAales, U. S. N., some years ago contrived an apparatus, which, he tells iis,^ was used successfully in twelve cases of fractured lower jaw. As figured in his work, it is very trig and sailor-like, well fitted to fulfill the indications for maintaining fractures of the lower maxilla; but perha])S, like so many others, too complicated to meet the exigencies of field practice. In the Union armies, softened binders’ board, secured by a four-tailed bandage, was the ordinary dressing. If there was much comminution, loose fragments were removed, and occasion- ally excisions were perfornied of portions of body or of the rami. In the base hospitals, complex apparatus of leather, gutta percha, papier mache, were employed, according to the prevailing fashion oi the section of country in which the hospital was situated."* * The experiment of wiring the fractured extremities of the maxilla, as proposed and practiced by Baudens, was occa,sionally employed ; but Dr. Bentley and otliers report unfavorably of this method, and several examples of ununited fracture are recorded, in which it had been adopted, with the additional dressing of Barton’s bandage. Wiring together the contigu- ous teeth was frequently yet not advantageously practiced. A pad of oakum under the cross-pieces of pasteboard was found convenient. Frequent detergent collutories, liquid food, and an antiphlogistic regimen were regarded as essential in the treatment. A solitary instance of fracture of the lower maxilla by a bayonet, is related on page 323. The fractures from falls and blows were . not infrequent. In the Army Medical Museum, specimens of thirty-two gunshot fractures of the lower jaw may be found, exhibiting many varieties of union, partial reparation, caries, and necrosis.^ A single additional illustration * Covey, Itichmmid Med and fSurr/. Jour., Viil. I, p. 81 ; BOLTON, p. ;!18. * “The surgeon accoinjianj-ing tlie transiuirts usually sends injuries of the face to the field infirmary untouehod, or should the lower jaw he hroken, applies a folded handkerchief or hand under it to support it. This fracture is jiernianently jiut up at the field infirmary in a pasteboard splint, well padded with carded cotton, and secured hy folded cloth or double-tailed bandage. One band passes over the vertex, supporting the jaws, while the other passes from the front of the chin behind the head, and then around the forehead, where it is secured hy pins, iiefore the dressings are apjdied (he wounds should have been examined carefully with the finger, and all [lerfectly detached spicula Of bone should have been removed. From (he exi'cssive vascularity cf all the ti.ssucs of this region the hones do not necrose as extensively as in other portions of the body, and portions of bone which are attached to the soft parts very often consolidate. The surge.,:i must be prcjiarcd to meet much swelling and profuse salivation. All gunshot injuries to the bones of (In^ face being compound, suppuration is soon estaldished, and the secretion of jnis is coiiious. AVhen the hall has i)erforul<'d th<^ buccal cavity, causing inllamma- tion and salivation, it will adk place, and death soon followed from exhaustion. The fractured maxilla is shown in the adjoining cut. It was contributed to the Army Medical Museum by Assistant Surgeon W. Thomson, U. S. A., and is No. 3542 of the Surgical Section. Wounds of the Buccal Cavity. — In the abstracts selected to illustrate the face wounds, many instances of lesions of the buccal cavity may be noted. Most of the gun- shot injuries of the jaws were of this class. Wounds complicated by lesions of the tongue, epiglottis, soft-palate, or glands of the mouth, or by the evulsion of several teeth were serious and very painful. Percy (1. c. p. 116) cites from Bartholin, Mangetus, and Pard examples of balls lodged from three to six years in the tongue. I have not observed any such instances in the records. The reader will not overlook the case of Jeffery (p. 357), where the wounded tongue contracted adhesions with the jaw, — or the cases of Lynn (p. 350), Schwartzlander (p. 355), and Stewart (p. 364), — all presenting remarkable complications of gunshot wounds of the tongue. In many of the wounds involving the alveolar processes and palatine arch, the aid of skilful dentists was sought advantageously. Hemorrhage in Wounds of the Face. — We can here consider the means adopted to suppress haemorrhage after wounds of the face, and more particularly after gunshot fractures of the facial bones. Unless some large arterial trunk was implicated, primary bleeding, that could not be controlled by judicious compression and cold applications, was rarely observed ; but the secondary haemorrhages following gunshot wounds of the facial bones were frequent and very dangerous. The abuse of styptics in this class of cases has been already adverted to. The profuse distribution of powders of persulphate and solu- tions of perchloride of iron in the field-case, paniers, knapsacks, and dispensaries appeared to invite ignorant orderlies or stewards to stuff every bleeding wound with lint or charpie saturated with undiluted solutions of these corrosive salts. The rule that the use of styptics, — other than cold, compression and position, — should be restricted within the nar- rowest limits, is nowhere more strictly applicable than in wounds of the face. Detailed abstracts have been given of the cases of Amos (p. 332), Martin (p. 339), Baine (p. 346), Beamenderfer, Copeland, and Cox (p. 347), Heiser (p. 349), Kilburn (p. 350), Merchant, Mcllroy, Murray, and Meinnis (p. 351), Maley (p. 352), Beeves and John B (p. 353), Stienberger (p. 355), and G. T (p. 392). And here may be introduced particulars regarding three other ligations of the common carotid, which are illustrated by pivparalions in the Army Medical Museum. SlCCT. 111.] EEVIEW, IIJiMOEEIlAGES AND LIGATIONS. 393 Case.— Sergeant Lyman A.E- , Co. D, 8th New York Heavy Artillery, aged 21 years, was wounded at EeanTs Station, August 2iith, 1804, by a musket ball, which entered over the right mastoid process, injured the external ear, and lodged under the skin, a little in front of the auditory foramen. In the difficult retreat from Beam’s Station, he was conveyed to the Base Hospital at City Point, and thence was sent to Washington and admitted to the Lincoln Hospital, on August 28th. The ball had not been extracted, and no symptoms attracted special attention until September 7th, when Acting Assistant Surgeon A. M. Sherman, in charge of the case, observed that the right parotid gland was so greatly iutlamed that the patient with difficulty sepa- rated his teeth more than one-fourth of an inch. In the course of the day, he had an alarming hsemorrhage, supj)osed to proceed from the posterior auricular. This was stopped by compression with lint steeped with solution of persulphate of iron. On September 8th, there was no recurrence of bleeding ; on the forenoon of the 9th, he had an alaiming haemorrhage, which was temporarily arrested, with difficulty, by compression with lint and styptics, until the patient could be removed to the operating room, when the right primitive carotid Avas ligated by Acting Assistant Surgeon W. W. Valk, the patient being etherized. The ligature Avas placed a short distance beloAV the bifurcation, and coagula Avere removed, and the ball, already mentioned, Avas extracted from near the angle of the jaAV. On the 10th, the patient was quiet, Avith a frequent pulse ; on the 11th, bleeding recurred, and again on the 12th, but ceased spontaneously. There Avas diarrhma and vomiting. On the 14th and 15th, the symptoms Avere regarded by Dr. Sherman as favorable. On the 18th there was several recurrences of htemorrhage ; on the 19th, there was much sAvelling of the face and neck, Avhen the ligature Avas removed. The patient died from haemorrhage on the folloAving day. The folloAving is an abstract of the notes made at the autopsy, by Acting Assistant Surgeon H. M. Dean : “Height, five feet seven inches. * * * * The submaxillary gland Avas in a suppurating condition ; * * the jugular vein Avas perfectly normal ; there Avas an abscess extending above and beloAv the point of the artery ligated about three-fourths of an inch ; the ligature had come away, and the tAvo extremities of the artery, at the point of ligation, Avere covered Avith pus.” The Avound already adverted to, behind the right ear, Avas connected Avith an abscess, Avhich extended doAvn to the angle of the inferior maxilla, and contained a dark- colored fcEtid pus. The artery from Avhich the hemorrhage came Avas not detected. The case is reported by Drs. Sherman and Dean, and Assistant Surgeon McKee, in his quarterly report, gives no further remarks on the case by Dr. Valk. The pathological specimen, figured in the Avood-cut, shoAvs one-third of the calibre of the vessel undivided. In the Avood-cut (Fig. 177), the ligature on the internal carotid AA'as apparently, as Dr. Woodhull has remarked, an experiment upon the cadaver. Case. — Private P. O’C- Fig. 177.-Innom- inata, pertiun of subclavian and three carotids, showing division by ulceration on the tentli day af- ter ligation of the common carotid. Spec. 3252, Sect. I, A. M. M. j Co. 18lh XJ, S. Infantry, was wounded at Chiclvamauga, September 20th, 1863, by a conoidal ball, Avhich'entered beloAV the left zygomatic arch, passed through to the right side, and made its exit beloAV the angle of the inferior maxilla. Secondary hemorrhage occurred from the Avound of exit and from the mouth on October 2d, but it Avas temporarily checked by compresses. October 4th Sur- geon Peter H. Cleary, U. S. V., ligated the external carotid. The patient improved rapidly and appeared perfectly safe, Avhen, on October 12th, haemorrhage recurred ; but Avas again checked by compression. The Avounds Avere nearly healed, but the patient Avas greatly enfeebled from repeated loss of blood. On October 23d, a profuse haemorrhage set in from the Avound of exit. Surgeon I. Moses, U. S. V., then ligated the right common carotid, about one and a half inches above its origin. The patient sank rapidly, and died on October 25th, 1863. The preparation, forAvarded to the Museum by Dr. Moses, U. S. V., is represented in the Avood-cut (FiG. 178). It shows a ligature of the common trunk, and, at the bifurcation, a large coagulum is imperfectly indicated. Above are the origins of the occipital and facial arteries, and, at the extremity, the rugose ulcerated section of the external carotid. Case. — Corporal G. P — Fig. 178.— Lig- ation of right car- otid. Spec. 2133, 8ect. I, A. M. M. -, Co. H, 91st Pennsylvania Volunteers, aged 28 years, was admitted to Emory Hospital, Washington, October 3l8t, 1864, for a gunshot wound of the face, received near South Side Eailroad, Virginia, October 27th. A ball had entered the chin at the left side, passed inAvard and lodged beneath the angle of the inferior maxilla, Avhence it Avas extracted through the mouth. The AVOund Avas dressed Avith cold Avater, and a compress Avas applied to the jaAV. On November 4th, secondary haemorrhage occurred, Avhich Avas arrested by plugging the Avound Avith sponges. The common carotid artery Avas tied in the continuity, just above the omo-hyoid, by Surgeon N. E. Moseley, U. S. V., for recur- ring hemorrhage on the 6th, and the patient died from exhaustion on the evening of Novem- ber 16th, 1864. The post-mortem examination revealed a firm clot in the artery. A Avet ju-eparation, shoAving the extent of this formation, Avas contributed to the Army liledical Museum by Acting Assistant Surgeon W. H. Coombs, and is rejiresented in the adjoining Avood-cut (Fig. 179). In Table XV, fifty-five cases of ligation of the conimon carotid after gunshot wounds of the face are accounted for, including two instances in which the external carotid was also tied. Twenty cases have been recited, with such particulars as \W'rc communicated. The remaining tliirty-five must he consolidated in a tahuhir statement. 50 394 WOUNDS AND INJURIES OF THE FACE. [ClIAP. II, OJ ^ G o OJ GO f*| ^ S ■"- ^ J <1> S 2 u 5 O ^ S ^ o • 'k S '-t: ^ ^ a; o ^ -op ^ CD S J § § ^ £ ° ^ g o; 45 CD ^ ;3 s a P o ^ ^ m I ^ P a CO ^ 3 ^■' P4‘ ^'5 ^ ^ g b o^.p jgr^ CO ^ ^ - [[o c» ci ^ S c£) -d OJ _ g G5 -g g .gc - g o a '-g b ^ o ,q -(—> S lO « hW O k^ •-4 ci ^ CO k'j CD cc! PP PP k— > -i-j a CD ^ ^ g g g p «. ^ ^ s 1^^ s -r M ^ 8 S ^ o b o p ^ ^ o P ^ p o '-8 7 P 1^ p: ^ p s ’Pp a O ^ b: ^ 7 CD m O .CD CtJ P-H bp ^ "p1 ub 2 b ffi'bi J S ,i ^ s“ C Co P > O O c5 -13 PP Co bJD CD 55 .a b s b p-i p 8 § 5- 7 o p 6 b ^ Ci ••'TP bb i 7 ^ o ’ jXJ p p P P o PP ^ -*-' o 1 1 Date of a J < 5 2 i 1 i 1 1 II i 1 1 I 55 : s' : 7':i : S' 2 f i 1 I ffi : I 1 1 1 ill I 1 Sb'3 i "' k. S ?< 2 : k, S 53 big ; = Date of Wound. ill ii III I f7 ^ CO co" ^*‘ tP o ^ ci III It III 1 11 1 1 S*" ^ t 3 & 1 O >-5 CO '-S LIGATION. Common carotid, j ust below bifurcation. Right common carotid Right common carotid... Comnn m earotid.j ust above omo-hyoid. Right common carotid. . .-. 1 Common carotid Right Common carotid Common carotid Right common carotid . . . .' Common carotid ! 1 Left comtnon carotid, at lower triangle. Right common candid, un- der omo-hyoid. 1 Common carotid ^ Right common carotid, near bifurcation. INJURY. G. S. F. of lower jaw G. S. W. of lower jaw G. S. F. of lower jaw, with wound of sublingual ar- tery. G. S. F. of lower jaw Conoidal musket ball frac- turing right upper max- illa. G. S. W. of mouth G. S. F. of inferior maxilla. G. S. F. of upperandlower jaw ; sight <)f one eye destroyed. G. S. F. of inferior maxilla. G. S. W. of face '■ i 4 ° bi 1 ? i 1 t s =S =• 3 “ If b| CO CO NASIE AND MIL. DES. Beard, J. J., Lieut. 19th Va. Cavalry. * Fuglcson, C., Serg't, 4th Ohio. Higgins, Pat'k, Private, 5Gth Kew York. Klingcnberg. C.. Private, 7th New York Artillery. Reed, James, 12th Mass R , J. R. r., JOtli Mass.. Sandy. N. B., I’rivate, Jd M'est Virginia. Siggins, T., Lieut., 4L)tli Mass 1 Salmon. G. A., Private. 27tli 1 Pennsylvania. ^Vaits, ir. ir.. Private, Gi.i .Simth Carolina Cavahy. Ashley, J. J., Citizen Bachvs. J. ir.. Private, 12th Georgia. Clark. J., Private 57th Penn- sylvania. Cronin. i\I., Private, 95th New York. . NO. r-i c* cc -r 1 - 00 Cl o f-H c? r*' 8kct. III.] KEVIEW, HAEMORRHAGES AND LIGATIONS. 395 396 WOUNDS AND INJUEIES OF THE FACE. [Chap. H, The results of ligation of the common carotid for gunshot injuries of the face were ascertained in fifty-four of the fifty-five cases reported. There were fifteen recoveries and thirty-nine deaths (or 72.2 per cent.) This mortality rate is larger, of course, than shown by the tabular state- ments of Dr. George Norris and others, for ligations of the carotid for all causes ; but not excessive for a series of ligations of the carotid for injury. In thirty-seven cases the affected side was noted. The right carotid was tied in twenty, and the left in six- teen cases. In Case 30, reported by Dr. Cheever, the ligature being applied on the fourteenth day after the injury, the patient had recurrent hsemorrhages ; but sur- vived until -the twenty-fourth day (Fig. 180). In the case of R. J. P (p. 349), death occurred on the eighth day after the reception of the wound. The specimen is FIG. 180.— Clot in left primary carotid. -Spec. 508, Sect. I, A. M. M. represented in the wood-cut. Fig. 181. Fig. 181. — Partial division of the extonial carotid, near the origin of the internal maxillary. Spec. 2222, Sect. I, A. M. M. Of the fifty-five ligations of the common carotid for gunshot face injuries, two were wounds of the soft parts only. The others involved fractures limited mainly to the mastoid or malar regions in nine instances, to the upper maxillary in twenty cases, to the lower maxilla in twenty-two cases, and extending to both jaws in three cases. The period intervening between the date of injury and the date of operation is known in forty-nine of the fifty-five cases cited, giving an average of eighteen days. The period between the date of operation and the date of death is recorded in thirty-eight of the thirty-nine fatal cases, averaging six days. The common carotid was re-ligated in four cases. In one instance (case of Fugleson, p. 394) the patient recovered ; in the other three, the men died on the same, the first and second day, respectively. There were six cases reported of ligations of the external carotid, in addition to the two already mentioned in conjunction with ligations of tlie common trunk. Four of the six may be regarded as successful, in the sense of recovery from the operation : Bryant, W., Private, 17th Indiana Volunteera. Gunshot wound of inferior maxilla, June 25th, 1863. Hiemorrhage occurred July 5th, 1863. Ligation of external carotid, July 5th, 1863. Hiemorrhage recurred, and artery je-ligated, July 8th, 1863. Recovered August 30th, 1863. In October, 1867, his disability was rated total and permanent. Diss, C., Private, 13th Ohio Volunteers. Gunshot fracture of right zygoma and malar bone; loss of eye, September 14th, 1862. -Hiemorrhage from right external carotid occurred September 22d, 1862. Artery ligated September 22d, 1862. Recov- ered November 19th, 1862. September 4th, 1865, Pension Examiner Th. A. Reamy stated that the right eye is sympathetically affected, and that the patient’s general system is failing rapidly. Pensioner died September 22d, 1865. Godfrey, A., Private, 14th New York Heavy Artillery. Gunshot wound of the jaw, June 18th, 1864. Hiemorrhage occurred from the external carotid, June 27th. Artery ligated June 27th, 1864, by Surgeon G. L. Pancoast, U. S. V. Patient died June 30th, 1864. Henderson, G., Sergeant, 7th Wisconsin Volunteers. Gunshot fracture of superior maxilla, September 14th, 1862, Hiemorrhage occurred from right external carotid, September 15th, 1862. Artery ligated September 15th. Recovered October 15th, 1862. In June, 1863, his disability was rated two- thirds and temporary. Nelson, G. W., Private, 12th Georgia Regiment. Gunshot fracture of zygoma, June 6th, 1864. Hffimorrhage occun-ed from left external carotid, June 6th and 7th. Artery ligated June 7th. Hannorrhage recurred June 19th. Died June 19th, 1864. Thompson, L. C., Private, 1st Texas Regiment. Gunshot fracture of right inferior maxilla, December 14th, 1864, Ilannorrhage occurred from right external carotid, December 14th, 1884. Artery ligated December 14th, 1864, by Surgeon J. C. .Jones, 4th Texas. Recovered January 14th, 1865. ' Skct. III.] EEVIEW, II^MOERIIAGES AND LIGATIONS. 397 A sifigle instance is noted of ligation of the internal jugular for a wound made in extracting a ball lodged behind the great vessels : Case. — Private William McDonald, Co. F, Slst New York Volunteers, was wounded at New Berne, March 14th, 18G2, by a musket ball, which entered the lower jaw, one and a half inches to the left of the symphysis, passed downward into the left side of the neck and lodged at the apex of the superior carotid triangle, between the jugular vein and the carotid artery. The haemorrhage was severe. He was treated at the New Berne Hospital till April 14th, and thence transferred to New York, and sent to Bellevue Hospital. On May 8th, he was transferred to Ladies’ Home Hospital. Loose pieces of bone were removed on June 15th, and, at subsequent periods, other fragments, in all amounting to sixteen. The wound finally healed, about Septem- ber 15th. At that date, he sufiered from numbness of left shoulder and partial paralysis of corresponding arm; he was unable to perform arduous duty, but was placed on light duty at the hospital. On January 5th, 1863, the bullet was removed by Surgeon Alexander B. Mott, U. S. V. In cutting down, over the ball, it was found that the relative anatomy of the part was deranged. The bullet was lying behind the deep jugular vein and carotid artery, and pressed the vein forward to such an extent that the vessel was collapsed and little or no blood could pass through it. The sui-rounding tissues also closely invested the missile. Although the incision was made through the sterno-cleido-mastoid muscle to the outside of the deep jugular vein, owing to the above facts it was accidentally wounded. The htemorrhage, however, was inconsiderable, being controlled by pressure, the danger of cutting the vein, and the probability of the accident having been duly announced by the operator previous to the operation. The ball ^vas extracted with some difficulty, and a double ligature passed around the vein so as to secure it above and below ; the wound was drawn together by interrupted sutures and adhesive straps. The ball was flattened on the posterior aspect and was very jagged where it was in contact with the carotid artery. The wound healed kindly, the ligatures coming away on the ninth day after the operation. The patient was finally discharged from service on April 13th, 1883. Pension Examining Surgeon G. S. Gale reports, September 30th, 1868, that exfoliation is still progressing; difficulty of deglutition ; left arm paralytic from probable injury of the cervical nerves. No instances of ligations of the internal carotid for gunshot injuries of the head or face were reported. The examples of tying the facial, lingual, superior thyroid, and other minor branches were but few, and the particulars reported but scanty.* The following citations will indicate what can be gleaned from the reports: Everson, P., Private, 1st Minnesota Volunteers. Gunshot wound through base of tongue, with fracture of jaw, July 2d, 1863. Hasmorrhage occurred July 14th, and both lingual arteries were tied in the wound en masse the same day. The patient recovered. In September, 1865, his general health was seriously impaired; he was unable to eat other than liquid food. Disability total. Atwood, G., Private, 142d New York Volunteers. Gunshot injury of inferior maxilla and fracture of left fibula, October 27th, 1864. Hcemorrhage occurred from a branch, of the superior thyroid, November 7th, 1864. Thyroid ligated November 7th, 1864. Recovered April 19th, 1865. In June, 1866, his disability was rated one-half anil permanent. Case. — Private Benjamin Foote, Co. I, 4th United States Colored Troops, aged 22 years, received, at Petersburg, June 15th, 1864, a gunshot wound through the upper maxillary. He was conveyed to Portsmouth, and, on June 20th, admitted to the Balfour Hospital. There was, apparently, little laceration or comminution, but the patient was much debilitated from profuse hajmorrhage. On June 23d, Acting Assistant Surgeon C. C. Ella ligated the right facial arteiy just below the com- mencement of the ascending palatine, but the case terminated fatally on the same day at ten in the evening. Case. — Private William Gaines, Co. C, 5th United States Colored Troops, aged 20 years, received, at Petersburg, June 18th, 1864, a gunshot wound of the face. The ball entered the left cheek, fractured the inferior maxilla, right side, and emerged from the right cheek, cutting- the right facial artery. He was conveyed to the Balfour Hospital, Portsmouth, on June 20th. Considerable laceration and comminution existed, especially on the right side. Secondary hicmorrhage occurred on June 25th, and, on the following day. Acting Assistant Surgeon C. C. Ella, ligated the right facial artery, near the inferior margin of the inferior maxillary. The patient improved steadily, and was transferred on July 19th, 1864. Bessel, A. J., Sergeant, 14th Michigan Volunteers. Gunshot fracture of inferior maxilla, light side, July 5th, 1864. Haemorrhage occuiTed and facial artery ligated. Discharged January 4th, 1865. McCray, J., Private, 145th Pennsylvania Volunteers. Gunshot wound of lower jaw. May 12th, 1864. Hannorrhage occurred June 4th, 1864. Facial artery ligated in wound, June 4th, 1884. Recovered July 1st, 1864. Woodward, C. L., Private, 2d Vermont Volunteers. Gunshot fracture of right lower jaw. May 3d, 1863. Ligation of left facial artery in wound. Recovered February 19th, 1864. * Consult, on ligations, Dr. Gurdon Buck {N. Y. Med. Times^ Nov., 1855). See tbe important papers of Dr. Geougk NOUlilS (Am. Jour. Med. Sci., 1847, Vol. XIV, p. 13) and the first in the Medico-Chirurgical Transactions (by Mr. ASTLEY Coopkk, and read Jan. 2yth, 180C) ; ]\I. 1*. BkOca, Dcs anevrysmes^ Paris, 18.35, p. 503; Dr. James U. Wood (iV. Y. Jour. Med., July, 18.57) ; N. CiiKVKliS, Lond. Med. Gaz., N. S., Vol. I, p. 1140 ; HoiCNRU, W. L., Ayner. Jour. Med. Sci., 1832, Vol. X, p. 403; BltOWN, J. B., Surgeon U. S. A., Am. Jour. Med. Sci., N. S., Vol. XXVIII, p. 415; Isaacs, C. K., N. Y. Jour, of Med.. \6\. X.V., ii. S., p. 151; see also Blackman, Western Lancet, Vol. XVl; TvviTCHELL, A'cw JCng. Jour. Med. and Surg., October, 1842; MUSSEV and COGSWELL, same Journal, Vol. XI, p. 359, and Vol. XIU, p, 357, 1824; Wauuen, J. C., JSoston Med. and Surg. Jour., Vol. I, p. 42, 1828, and LEWIS, same Journal, Vol. II, p. 371, 1829. 398 WOUNDS AND INJURIES OF THE FACE. [Chap. II, Leaving the ligations, which will be reverted to in connection with operations for injuries of the neck, it may he noted that hut few of the cases reported as excisions appear to have heen extensive operations; hut rather the removal of portions of hone that were partially detached or had perished from necrosis and required slight operative interference for their extraction. Yet there were important exceiDtions to this general statement, as in the cases of Downey (p. 348) and Spear (p. 365), where formal excisions were practiced of portions of the upper maxillaries, and those of Beamenderfer (p. 347), Murray (p. 351), Smith (p. 362), and Algoe (p. 365), in which considerable parts of the lower maxilla were excised. Most of these were intermediary opera- tions; hut several were performed at the field hospitals. In two or three instances staphyloraphy was early performed, and quite success- fully in a case noted on p. 378. Commonly, wounds of the palatine region were too extensive to admit of an ojieration of such nicety. Of trephining the antrum to extract halls, a very few cases were reported, and one only (Keil, p. 366) in any detail. An example of a hall splitting on the symphysis of the lower maxilla, after wounding the right common carotid, is illustrated hy Fig. Fic. ] 82 .— conoidai ball, ig2. All iiistance of the extraction from the orhit of two pieces of wire Split on impact with lower -L i,“a.' m! is described and figured in the following case : Case. — I’rivate Simon Flory, Co. F, 1st Peiinsj'lvania Artillery, aged 22 years, was admitted to Tumor’s Lane Hospital, Pbiladelpliia, on July lltli, for a wound of the eye, received at Gettysburg, July 2d, 1863. A piece of iron wire, possibly from a case-sbot, bad entered tbe upper and inner part of tbe right oi-bit, and lodged. It was at once removed by tbe regimental surgeon, being bi’oken in two pieces. By December 12tb, tbe wound bad bealed, but tbe sight of the eye was destroyed. The above particulars, with the specimen, which is rejiresented in tbe adjoining cut (Fig. 183) were contributed by Assistant Surgeon C. H. Alden, U. S. A. Tbe man is a pensioner, and bis disability was rated one-lialf in December, 1865, tbe eye being amaurotic. Examining Surgeon J. J. Crawferd, of Williamsport, Lycoming County, Pennsylvania, under date of September lltb, 1866, states: “Tbe projectile, a piece of canister wire tbe shape of a half circle, entered one point above tbe right eyeball, tbe other at tbe inner cantbus of tbe same eye. Tbe supra-orbital nerve was wounded by the upper point, and tbe violent concussion of tbe brain Fic..l83. — Iron wire removed injured tbe optic nerve. Tlie eye is amaurotic.” Tbe foreign body was removed by Surgeon M. aTi' aF F. Price, 1st Pennsylvania Artillery. Ill the shocking cases in which the greater portion of the lower maxilla was carried away hy large projectiles, or where considerahle parts of both jaws were destroyed, the mortality was far less than might have heen anticipated. In many of these instances, ingenious prothetic apparatus was ada]ited, and the mutilated men were enabled to retain liquid food, and to avoid the dribbling of saliva, as well as to mask their deformities. No examples were reported of halls remaining lodged for a long time in the tongue, such as Larrey records. The most important complication of wounds of the face, viz: hsemorrhage, will he reverted to in connection with wounds of the neck.* * C’onsiilt Holmes, op. cit.. VdL II, p. 183; DoniilCLIN, Dc Ifniendis Vulnerum Oris^ Halae ; WisEMAN, Several Chiruryical 2'rcatise.s, London, 1G76, p. 301; RlliES, Diet, dcs Sci. Mid., Paris, 1818, T. 29, p. 375; Oaiiuetsox, A Treatise on the Diseases and Surgery of the Mouthy Jaws, and, Associated Parts, Phila., 1809; JoL’DATX, A Treatise on the. Diseases and Surgical Operations of the Mouth and ]*oxts Adjacent, Phila., 1851; Mal- GAIGNlC, Traitc dcs Fractures ct des Luxations, Paris, 1874, T. I, p. 378 ; Journ. Gen. de Medicitie, T. LXIII, p. 4, and T. LXVI, p. 80 ; Rccua Medicate, 1824, T.'lV, p. 405; Diet, dc Medicine, Paris, 1832-1845, T. XIX : HOUZELOT, These Inaug., I’aris, 1827; NeUCOUT. Ohs. de Fract. dc la Mathoirc hf.; Journ. dc Chir., 1844, j). 359: DESAULT, Journ. dc Chir., 'Ik 1, j). 8; Lecat, Remarques siir une, Especc Part, de Fract. dc la Machoire Inf., Stqqjle- merit uux In.d. Chir. d' IlEISTEU, p. 154 ; ROSSI, Med. Operat., T. I, p. 78; VIDAL, Traiti dc l*ath. Ext., Paris, 1801, 'V. Ill, p. 502; FLAJAN'J, Colledone di os.w.ri'aziom, etc., Roma. 1802, T. Ill, j). 100; Annates dc la Chirurgic, T. VIII, p. 472; MiCIIAELIS, licschrcihung, etc.. Journal der Chirurgic VON (illALEE nnd Waltiie:!, 1823; BlAlAUD, Gaz. dcs Ilopitaux, 19 Aodt, 1841; BUSH, Lrmdoii Med. and Phys. Journal, Nov., 1822, p. 401 ; Wales, A Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations, Phila., 1807; PKIiCV, 1. c. p. IKi; BoYEU, 1. c. ; DelalajX, Bulletin de I Acad, d,- Med., Paris, April Ifith, 1872. CHAPTER III. WOUNDS AND INJURIES OP THE NECK. The wounds and injuries, of the neck reported, and here to be considered, numbered about five thousand. The results are tabulated at the conclusion of the chapter. So many injuries of the neck were comjDlicated, either by lesions of the face, or of the chest, or of the cervical vertebrae, or of the great vessels of the neck, that the conclusions must be regarded as approximative only, a large number of cases being elsewhere classified. Many ligations of the carotids are included. The injuries of the spine are separately considered in the fourth chapter. This chapter will include sections on miscellaneous injuries, on gunshot wounds, and on operations. Section I. INCISED AND PUNCTUEED WOUNDS, AND MISCELLANEOUS INJUEIES. Forty-six cases of this nature appear on the returns, comprising a few sabre and bayonet wounds, suicidal attempts with razors, stabs from knives, and contusions from various causes. The cases of sabre and bayonet wounds will be specified, and the remaining cases tabulated. There was one instance of an unimportant injury from a fragment of a torpedo. Sabre Wounds. — There were five cases that came under treatment, as follows: I.irrr.K, ,J. II., I’l-ivate, Co. B, IStli I’emifiylvania Cavalry, agvd 24 years. Elesh wouiul of left side of iieclv ; salire. Satterlee Hosi'ital, Bliila(leli)liia. Duty, January 2:5<1, 18:14. I’aytox, William, Puvato, Co. K, fc’lli West Virginia Cavalry, aged 22 years. Sabre wound of left side of iiedv. Bunker Hill, Virginia, Sejiteiiiber 3d, 18t)4. Division No. 1 Hospital, Annapolis, October 9tb. Deserted, Noveinlier 29tl], 18:14. McIntO-SII, Daa id, Sergeant, Co. E, Gtb Ohio Cavalry. Sabre wound of back of neck. Cavalry raid in Virginia, May 9tb to l.utl), 18G4. Mooxicy, Daxiicl T., Private, Co. H, 2d New .Jersey Cavalry. Sabre wound of ligbt side of neck. Ninvark Hcspifal, Newark, New Jer.sey, I'ebruary 22d, 1834. Disebarged April 8tli, 18o5, for unreducible dislocation of right shoulder. .Jacobs Thoma.s, Piivate, Co. I, 1st Potomac Home Brigade. Sabre wound of neck; slight. Monocacy Junction, Marylan;!, July Dth, 18, i4. Hospital at Frederick, Jidy 13th, 1804. Transferred to Baltimore, and returned to duty on August •2d, 1834. 3'./J 400 WOUNDS AND INJURIES OF THE NECK. [Chap. Ill, Bayonet Wounds. — Three slight cases and one that was fatal were reported. In the latter, the great vessels of the neck were perforated : Hassetf, B. J., Bugler, Co. F, 121st New York Volunteers, aged 19 years. Bayonet wound of right side of neck ; slight. Wilderness, May 5th, 1854. Washington, Baltimore, and Annapolis hospitals. Returned to duty on August IGth, 1864. !Mooke, James, Corporal, Co. D, 38th Ohio Volunteers, aged 24 years. Bayonet wound of neck. Jonesboro’, Georgia, September 1st, 1804. Nashville, Cincinnati. Mustered out on June 21st, 1865. Dustin, Elbridge, Private, Co. B, 9th New Hampshire. Bayonet wound of neck. Jackson, Mississippi, July 13th, 1863. Surprised on picket and brought into hospital dead.* Littxe, John N., Sergeant, Co. I, 2d West Virginia Volunteers. Bayonet wound of neck, posterior to pharynx, April 18th, 1865. Discharged on June 21st, 1865. Table XVI. Jxesults of Forty-six Cases of Injuries of the Neele from Miscellaneous Causes. CHARACTER OF INJURY. Cases. Duty. Disciiauged. Dnsn. UNKNOWN. 5 2 2 1 4 1 2 1 9 6 3 2 1 1 Incised Wounds (not sabre) 27 16 4 5 2 Aggregates 47 26 8 6 7 The more important incised wounds of the neck were self-inflicted, in awkward attempts at suicide ; the knife being applied too high up, missed the great vessels. A remarkable illustration may be cited: Case. — Private J. L. McC , Co. C, 23d Massachusetts Volunteers, entered Academy Hospital, New Berne, April 9th, 1862. He had cut his throat at the level of the crico-thyroid cartilage, the incision severing the larynx and oesophagus, and extending to the inner borders of the sterno-mastoid. He fiercely resisted any attempt to dress his wound or to introduce a stomach tube. The bleeding was comparatively unimportant. The most remarkable feature of the case was the sufferer’s intense thirst. From a pail of water, placed above the level of his head, he could suck through a rubber tube, by bending forward and closing the wound, a little water that was apparently swallowed ; — then, using the tube as a syphon, he would let the water pass through the pharyn.x and escape through the wound. He required eight pailfuls, or twenty gallons of water daily. Unavail- ing attempts were made to anaesthetize him in order to admininister nourishment. He died exhausted on April 15th, 1862. Case. — H. W , jailor, was hanged at Washington, November 10th, 1865. He was about 40 years of age, and weighed about 160 pounds. The rope was half an inch in diameter; the knot was placed under the left ear ; the fall was five feet. The body was suspended for fifteen minutes and then removed to the hospital. No rigor, no relaxation of sphincters, no . seminal ejaculation. Face pallid; eyes not congested, pupils dilated; mouth open, but tongue not protruding. Cicatrices on left shoulder, forearm, and legs, of old ulcers, probably scorbutic. A deep sulcus, with tumefaction of the adjacent soft parts. Laceration of the inner fibres of the trapezius and of the belly of the sterno-mastoid was observed on removing the skin. The hyoid bone had received six injuries — separation of the greater and lesser processes on both sides from the body of the bone and true ft-acture of the outer third of the greater process on either side. There was no lesion of the brain. The atlas and axis had not been luxated, and the spinal cord had escaped compression. In the thorax, old jileuritic adhesions ; aortic insufficiency, with calcareous deposits ; in the abdomen, nothing abnoi'mal. On the right forearm were cicatrices and two small indolent ulcei’s, involving the integuments only. The bones of the forearm had not been fractured or resected. Drs. W. Thomson and H. Allen, from whose official report the foregoing notes are taken, remark the extreme rarity of fractures of the hyoid. Death resulted from apnoea alone. The specimens forwarded with the report are Nos. 298 to 302, inclusive, in the Surgical Section. The preparation of the hyoid is represented in the wood-cut (Fig. 184). * See Reports of Surgeon W. A. Webster, 9tli New H.nmpshire Vols., and of Natt Head, Adjutant General of N. H. Sect. II.] GUNSHOT WOUNDS OF THE NECK. 401 Section II. GUNSHOT WOUNDS. Gunshot wounds of the neck may be subdivided into tliose of tlie anterior, lateral, or posterior cervical region. The injuries of the anterior region may bo grouped in two lesser divisions — as they are inflicted above or below the hyoid bone. Among them, wounds of the larynx, hyoid bone, trachea, pharynx, and oesophagus are presented for consideration. In the lateral region, lesions of the great vessels, of the pneumogastric and sympathetic nerves, and of the chain of lymphatic glands are encountered. The posterior sub-region, occupied by strong muscles, with comparatively unimportant nerves, vessels, and lymphatics, is of less interest, in a surgical point of view, than the others. A few abstracts of the gunshot flesh wounds may be noted : Case. — Lieutenant John O’Connor, Co. A, 7th Missouri Volunteers, received a gunshot wound of the neck, at Vicksburg, Mississippi, May 22d, 1863. The missile entered the posterior superior process of the scapula, passed upward and emerged one inch below the angle of the right jaw. He was treated in the field hospital until June 22d, when he entered the City Hospital, St. Louis, Missouri. On July 24th, he was transferred to Jefierson Barracks, and finally mustered out at the exjjiration of his term of service on June 14th, 1864. He is not a pensioner. Case. — Private Allen Gregg, Co. A, 73d Indiana Volunteers, was wounded at Day's Gap, Alabama, April 30th, 1863, a buckshot entering at the back of the right ear and emerging from the posterior aspect of the nock. On May 27th, ho was admitted to the 1st division hospital, Annapolis, Maryland. The wounds healed, and he was returned to duty on March 1st, 1864. He is not a pensioner. Case. — ^Private John Knuller, Co. E, 1st Michigan Cavalry, aged 38 years, received a gunshot wound of the neck at Cold Harbor, Virginia, June 3d, 1864, a conoidal ball entering the left side, just below the occipital ]irotuberauce, and emei’ging above the seventh cervical vertebra. He was taken to the hospital of the 1st division. Cavalry Corps, where simple dressings were applied to the wound. On June 7th, he was sent to Ilarewood Hospital ; on June 18th, to Summit House Ilospit.al, Philadelphia, and, on August 18th, to the Satterlee Hospital. By October 25th, the wound of exit had entirely healed, but reopened on Decem- ber 25th, discharging freely. On .July 18th, 1835, lie was transferred to Harper Hospital, Detroit, Michigan, and discharged from service on October 2d, 1865. He is not a pensioner. Case. — Private Franklin Smith, Co. B, 28th United States Colored Troops, of an athletic constitution, was wounded in the left side of the neck at Camp Fremont, Indiana, April 24th, 1834, a pistol ball striking near the angle of the maxilla, posterior to the carotid artery. He was taken to the regimental hospital, where simple dressings were ajiplied to the wound. It was said that immediately after the reception of the injury, the ball was distinctly felt one inch and a half below the point of abrasion, the surface of which might be said to be hermetically closed. He was not confined to the hospital, apparently sufl'eriug but little from his wound. He is not a pensioner. Case. — Private J. J. Gibson, 17th South Carolina Regiment, aged 21 years, received a gunshot wound of the throat, near Petersburg, Virginia, August 6th, 1864, the missile entering below the external meatus of the left side, and emerging in the inferior triangle on the right side of the neck. He was taken to the Confederate Hospital, Petersburg, and furloughed on August 27th, 1864. The next case was regarded by Surgeon J. II. Brinton, U. S. V., as an excellent illus- tration of the incised appearance occasionally presented by the entrance wounds of conoidal balls, and a water-colored drawing (No. II, Surgical Series) was made, by Dr. Briuton’s direction, by Hospital Steward E. Stauch. This is carefully copied in the left-hand figure of the chromo-lithograph facing page 367. 51 402 WOUNDS AND INJIIEIES OF THE NECK. [Chap. Ill, Case. — Private Anthony Speigle, Co. K, 5th United States Cavalry, was wounded at Beverly Ford, Virginia, June 9th, 18G3, by a hall, which entered the hack of the neck and passed out on the right side some two inches above the clavicle. He was sent to Washington ; .admitted to Lincoln Ilosjiital on the 10th; transferred to Philadelphia on the 22d, and admitted to the McClellan Hospital on the 2od. By this time a cicatri.x; had formed. He \vas returned to duty cured on August 23d, 18G3. Speigle is not a pensioner. Case. — Private J. H. McKittrick, Co. F, 66th Ohio Volunteers, aged 20 years, received a gunshot wound of the neck at Cedar Mountain, Virginia, August 9th, 1862. The missile entered just behind and at the base of the lobe of the left ear, passed forward beneath the integument, and emerged at about the middle of the chest. He was admitted, op the 13th, to the 3d division hospit.al, Alexandria, Virginia, where cold water dressings were applied to the wound. He was transferred on August 30th, 1862, at which time he was doing well. He is not a pensioner. Case. — Corporal Uriah F. Snediker, Co. H, 2d Connecticut Heavy Artillery, aged 23 years, received a gunshot wound of the neck, by a conoidal ball, at Cold Harbor, Virginia, June 1st, 1864. He was taken to the hospital of the 1st division. Sixth Corps, and cold water dressings were applied to the wound. On June 6th, he was sent to the Soldier’s Eest Hospital, Alexandria; on June 16th, to Mower Hospital, Philadelphia, and, on July 13th, to Knight Hospital, New Haven, Connecticut, whence he was discharged the service on June 7th, 1865. He is not a pensioner. Case. — Private Joseph S. Hambright, Co. F, 17th South Carolina, aged 19 years, was wounded at Burkesville, Virginia, April 9th, 1865, by a conoidal ball, which entered in front of the lobe of the left ear and emerged one and a half inches below the occipital protuberance. He was taken prisoner, and, on the 11th, admitted to the hospital of the Tenth Corps, near Humphrey’s Stiition. On April 19th, he was sent to Lincoln Hospital, Washington, whence he was released on June 9th, 1865. Case. — Private A. J. Bowen, Co. E, 48th Georgia, aged 27 years, was wounded at Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal ball, which entered about the centre of the inner border of the trapezius muscle, right side, passed beneath th.at muscle, and emerged from the back between the inferior angle of the scapula and the spine. Another ball entered the right side of the back over the tenth rib, passed horizontally across and emerged about one and a half inches from the spine. He also received a wound of the scalp on the back and left side of the head, about three inches in length and one and a half inches in width, which was apparently caused by a fragment of shell. He was taken prisoner and conveyed to the Seminary Hospital, Gettysburg. Cold water dressings were applied to the wound, and tonics and stimulants given, with a Dover’s powder at night. By July 15th, the wounds in the neck and back were suppurating freely; the discharges were healthy. His appetite was gone, and he was very much disheartened and reduced. On the 18th, there was considerable inflammation around the wounds in the back, and, on the 19th, erysipelatous inflammation set in, extending fi’om the umbilicus around the body up to the neck. The face was also inflamed, the eyes being completely closed, and the skin was in a frightful mdematous condition. The wounds looked healthy, with the exception of the neck. There was considerable hasmorrhage during the night. Pulse faint. A local application of tincture of iodine was made, and beef tea given. On the 20th, the inflammation on the body had subsided; the face and eyes were still oedematous. He continued to improve, and, on July 27th, was sent to the hospital at Camp Letterman, whence he was transferred to the Provost Marshal on September 16th, 1863, for exchange. The two following cases are illustrated , by a plate copied from the water-colored drawing, made by Dr. Brinton’s direction, to illustrate the appearances of entrance and exit gunshot wounds. The first figure illustrates how a ball may almost harmlessly traverse a region containing organs of vital importance; and the second illustrates the resiliency of the great vessels of the neck. It was the opinion of several surgeons, who saw the case, that the ball had passed through the sheath of the carotid, and probably between the carotid and jugular vein: Case. — Private George W. Brown, Co. I, 4th Vermont Volunteers, was wounded at Fredericksburg, on May 3d, 1863, by a conoidal musket ball fired at a distance of thirty yards. The missile having entered the neck posteriorly on the right side, passed into the mouth, knocking out three of the lower teeth, and escaped. Being sent to Washington, the patient was admitted to the Judiciary Square Hospital on the 8th; the wound was dressed simply. On the 9th, he was transferred to De Camp Hospital, New York Harbor, and, on July 16th, to General Hospital at Brattleboro’, Vermont. He was returned to duty on November Gth, 1863. Case. — Private Joseph Keepers, Co. G, 17th Pennsylvania Cavalry, was wounded in the neck at Beverly Ford, Virginia, June 9th, 1863. He was mounted at the time, and distant from the enemy about one hundred and fifty yards. The missile, a conoidal ball, entered the right side of the neck, just below the chin, at the anterior border of the sterno-mastoid muscle, and, passing backwards about three inches, emerged. There was excessive haemorrhage, and the shock was great. The patient being sent to Washington was admitted to Lincoln Hospital on the 10th; ice was applied to the wound; low diet ordered. On June 11th, the wound was very painful ; treatment continued. June 16th, steadily improving, very little discharge from wound, water dressing, half diet; June 19th, free discharge, full diet. On June 22d, he was transferred to Philadelphia, and admitted to the McClellan Hospital. His condition at that time was good, and the wound is reported to have healed without any changes or symptoms worthy of notice. On April 15th, 1834, the patient is reported to be unable to turn his head freely from side to side, in consequence of the sterno-cleido-mastoid muscle having lost its function. He was transferred to duty in the Veteran Reserve Corps, May 3d, 1864. Examining Surgeon J. L. Suesserott, of Chambersburg, Pennsylvania, reported March 9th, 1867, that * * * “his right arm is weak and somewhat atrophied.” His disability is rated at the Pension Office as one-half and not permanent. Mi ll H Sur'X Hist . of llu‘ \\';ir ol’ the R(>l)t'llii)n, I'iirt l.Vol II Op.jinoc -l-Oi; U. ff.C.MMiiown.tSoi-paso Pt . ,1 . K<‘ei>i'rs ,( See pa-ie 1-02. PLATE IX. WOUNDS OF THE NECK BY CONOIDAL MUSKET BALLS. Skct. II.] BALLS LODGED, EXTEACTED, OR DISCHARGED. 403 There were others pensioned on account of wounds of the neck, regarding whom it was difficult to decide, (“ither from the hospital or pension reports, whether they were slightly or seriously injured : Case. — Private John Valentine, Co. K, 88th Pennsylvania Volunteers, aged 19 years, was wounded at Cold Harbor, May 30th, 1864, hy a conoidal hall, which entered the right side of the neck, near the inner border of the trapezius muscle, passed obliquely downward, and to the left, and emerged near the axillary border of the lower angle of the scapula. He was, on June 4th, admitted to Mount Pleasant Hospital, Washington, and, on June 9th, transferred to Philadelphia, where he was admitted to the South Street Hospital on June 13th. Simple dressings were applied to the wound, also compress Wet with lead water, and tincture of iodine was painted over the track of the ball. Milk punch was freely administered. The wound discharged pus fi'eely, and the patient was very weak. On July 21st, the wounds were healed. He was returned to duty on September 8th, 1864. On May 14th, 1866, Pension Examiner J. Cummiskey reports that the patient has a gi’eat deal of pain in the back of the neck, and feebleness of the left arm, which has existed since the reception of the wound. Case. — Private B. F. Hawkins, Co. D, 7th Ohio Volunteers, received a gunshot wound of the neck at Port Republic, Virginia, June 9th, 1862. The missile entered above the middle of the spine of the scapula on the right side, and emerged at the middle of the stemo-cleido mastoid muscle, anterior border. He was admitted to Cliffburne llospit.al, W'ashington, Juno 15th, 1862, and returned to duty on August 5th. On August 12th, he was admitted to the 3d division hospital, Alexandria, and again returned to duty on March 2d, 1863. Pension Examiner A. O’Brien reports, September 6th, 1866, that the muscles which elevate the arm were cut across. Many fatal cases were reported so indefinitely, that it was possible only to conjecture the probable cause of death, the extent and nature of the wounds, and character of the succeeding symptoms being referred to with extreme brevity, if at all. The following may serve as illustrations of this class : Case. — Private Thomas Mcllvaine, Co. E, llOth Pennsylvania Volunteers, was wounded at Winchester, March 23d, 1862, by a musket ball, which entered one inch below and behind the mastoid process, and emerged over the spinous process of the third cervical vertebra. On April 2d, he was admitted into Saint Joseph’s Hospital, New York, with slight fever. Simple dressings were applied to the wound. Sulphate of quinine, refrigerant drinks, tonics, and milk punch were administered, and nourishing diet ordered. Profuse epistaxis occurred on April 7th, and recurred on the 8th, when gastritis, followed hy hmma- temesis set in. On April 12th, the patient was unable to articulate ; difficult deglutition and involuntary evacuations ensued ; he sank gradually, and died on April 13th, 1862. Case. — Corporal Warren Eutan, Co. I, 1st New Jersey Cavalry, aged 20 years, received a gunshot wound of the neck by a conoidal ball, at Salem Church, Virginia, May 28th, 1864. He was taken to the hospital of the 2d division. Cavalry Corps; on Jime 4th, sent to Mount Pleasant Hospital, Washington; on June 10th, to DeCamp Hospital, New York; on June 14th, to Grant Hospital, New York ; and finally, on October 20th, 1864, to Ward Hospital, Newark, N. J. He died while at home on furlough, March 21st, 1865. Case. — Private George W. Buffum, Co. D, 5th Wisconsin Volunteers, aged 39 years, received, at Harper’s Farm, Virginia, April 6th, 1865, a gunshot wound of the shoulder and neck, by a conoidal ball. He was taken to the hospital of the 3d division. Ninth Corps, and on April 15th, sent to the hospital at Annapolis, Maryland. When admitted he was much exhausted, and partially delirious. He suffered extreme pain in the injured parts. His ap])etite was poor, and he was able to retain but a small quantity of solid food. Dry oakum was applied to the wound, and tonics and stimulants administered. Death resulted on April 28th, 1865. Balls lodged, extracted, or discharged. — In one hundred and thirty-six cases of gunshot wounds of the neck, the missile lodged. From these numerous examples of lodgment of small projectiles in the neck, the following abstracts are selected. In most cases of this class (in eighty-seven, to speak .more precisely), the missiles were extracted ; in others, they were probably encysted, causing no immediate inconvenience ; less frequently, they gravitated through the soft parts, toward the nearest cavity or exterior surface, and were eliminated spontaneously : Case. — Private John R. Fletcher, Co. A, 10th Illinois Cavalry, received a gunshot wound of the neck at Bayou Teche, Arkansas, September 10th, 1863, the ball lodging in the complexus muscles of the left side. He was admitted, on the next day, to the hospital at Little Rock, where the ball was removed, and he was returned to duty on October 23d, 1863. He is not a pensioner. Case. — Private Ludovico Bowles, Co. D, 24th Michigan Volunteers, was wounded at Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, which entered the left side of the neck just below the submaxillary gland, traversed the base of the tongue, and lodged upon the right side just below the base of the jaw. He was taken to the regimental hosj)ital ; tlie ball could 404 WOUNDS AND INJURIES OF THE NECK. [Chap. Ill, be felt in se.at of loilgnieiit. The p.aticnt was so refractory that it could not bo cut to in the mouth, wlioro the incision would havo been slight. I’ai-tial aucesthesia was induced with difficulty. The ball was pressed by the finger, below the right sub- inaxillaiy gland, the forceps had been i)assed to the ball by way of entrance, but extraction was imjrracticable. On June 14th, he was sent to Mount Pleasant Hospital, Washington, and, on June ICth, to IVest’s Buildings Hospital, Baltimore, whence he was returned to duty on July 3d, 1863. He is not a pensioner. Case. — Private Isaac D. Davis, Co. I, 156th New York, was wounded at Fort Bisland, Louisiana, April 9th, 1863, by a fragment of shell, which struck the posterior surface of the neck. The missile was cut out. In August, 1837, Davis reenlisted in the Veter.an Reserve Corps. There was not any bad result; the movements were normal. He was also injured by a fall at Alexandria, Louisiana, causing a fracture of the left elbow-joint. The movement of the joint was very fair. It was suspected there was a rupture of the circular ligament, for which he was treated by flexion at right angle. His health was good. He was discharged from service on April 7th, 1839. His claim for pension is pending. Ca.se. — Corporal Albion L. Jackson, Co, I, 13th Massachusetts Volunteers, was wounded at Gettysburg, Pennsylvania, July 1st, 1863, by a conoidal ball, which entered near the malar process of the left superior maxillary bone and lodged beneath the angle of the left. He was admitted on the same day to the regimental hospital. For three weeks afterward a hard substance could be felt beneath the angle of the jaw, when it disappeared, and the left side of the pharynx, corresponding, began to be swollen. He returned to his regiment suft'eriiig no inconvenience from his wound, which had healed, nor from the swollen pharynx, except a slight pain on deglutition, which would be increased on taking cold, when also bloody matter would be expectorated. On the morning of October 28th, 1333, he was awakened by something in his throat, which, with a little effort, was spit out and proved to be a conoidal lead bullet, so flattened at its base as to form, on one side of it, nearly parallel lips, which held between them some apparently fibrous and earthy substance. At the time the bullet was discharged, there was but slight expectoration, and the swelling and soreness of the pharynx soon disappeared. He is not a pensioner. Case. — Private William Herbert, Co. H, 159th New York Volunteers, aged 22 years, was wounded at Cedar Creek, October 19th, 1834, by a conoidal ball, which entered at the left side of the sixth cervical vertebra, and lodged just above the middle of the left clavicle. He was conveyed to the hospital of the 2d division. Nineteenth Corps, and transferred to Baltimore, where he was admitted into the Jarvis Hospital on October 27th. Simple dressings were applied to the wound. The missile w.as extracted on November 7th. On December 11th, he was admitted to Mower Hospital, Philadelphia, whence he was discharged the service on June 7th, 1835. On October 25th, Pension Examiner Charles Rowland, stated that Herbert had pain in the left breast, with severe cough, and general debility, resulting from the wound. In the following case, an inch and a quarter grape-shot, from a battery about three hundred yards distant, was deflected on striking the hyoid bone, and buried itself in the muscles over the right shoulder-blade, whence I cut it out. He died on the fourth day from oedema of the glottis ; Case. — Private Fi’ederick Soule, Co. F, 27th Massachusetts Volunteers, was wounded at New Berne, March 14th, 1862, by a large grape shot. The missile entered near the right b.orn of the hyoid bone, passed obliquely across the neck, and lodged in the subscapular fossa, from which it was removed by an incision. Very little irritative fever supervened. Water dressings were applied to the wound, and morphine administered. On the night of March 18th, 1832, the patient was unexpectedly seized with a choking fit, and died suddenly half an hour thereafter.* Case. — Private George R. Boorman, Co. H, 18th United States Infantry, was wounded at Chickamauga, Georgia, September 20th, 1863, by a conoidal ball, which entered the left side of the neck, a little above the level of the thyroid cartilage, passed through the sterno-mastoid, and, ranging forward and downward, lodged. He was admitted on the next day to the hospital at Chattanooga, Tennessee. There was considerable swelling of the left side of the neck, and most oppressive dyspnoea. On September 24th, a solid foreign substance, which was decided to be the ball, was detected lying at the sternal extremity of the left clavicle, at which point there existed the greatest degree of swelling. The wound of entrance was care- fully enlarged, and the bidl removed by forceps after it had been raised by external manipulation. During the operation a consider.able amount of pus was evacuated. His breathing was but little improved, even for a short time, and death resulted on the morning of September 25th, 1833, from ajjnoea. At the autopsy, eight hours after death, the fact was revealed that the sheath of the common carotid artery, together with the trachea, served for a part of the wall of the abscess ; no part of the air passages had been penetrated by the ball or pus. The bronchial glands were very much enlarged, and all the tissues covering the anterior part of the neck wore so much congested and swollen as to preclude the possibility of jierforming tracheotomy. The left side of the thyroid cartilage bore evidence of having been struck by the ball. Beneath the cartilage proper and its mucous lining wa-s a thin layer of coagulated blood. Within the larynx were all the evidences of general laryngitis ; muco-purulent matter, with congestion, producing nearly entire occlusion of the air passages. The conoidal extremity of the ball was bruised on one side and grooved as if from striking some solid body. ^ Case. — Corporal Janies' A. llayes, Co. A, 6th Alabama Regiment, aged 18 year.s, was wounded at South Mountain, September 14th, 1832, by a conoidal ball, which entered above the clavicle, and lodged between the scapula and the spinal column, right side. He was, on September 24th, admitted to National Hospital, Baltimore. Simple dressings were applied to the wound ; tonics and stimulants were administered. An abscess had formed around the ball, and a (piantity of pus flowed through the incision made to remove the ball. The patient had one attack of erysipilas. On November 29th, he was sent to the South to be exchauged, cured. * See Kepvt of the Wounded ut the, Iluttle of Neu’ Jh'.rne, Amcrioan ]Mcili<'al Tiiuos, J uly .'5, 18fi2. Sect. II.] FOREIGN BODIES EXTRACTEp. 405 Case. — Private Joniel Leonard. Co. I, 38th Indiana Volunteers, aj'od 21 yeans, received, at Perryville, October 8th, 1882, a gunshot wound of the back of the neck ; also a gunshot fracture of the os calcis; the ball lodged. He was, on October 26th, admitted to Hospital No. 1, Louisville. On admission, the wound of the heel presented an indolent, flabby appearance.' Linseed poultices were applied to the wound, belladonna plaster to the back, and tonics, stimulants, and opiates were adminis- tered. On November 2d, tetanus aj)pearod, trismus, with quick contraction of the extensor muscles, occurring in spasms ; the bowels were costive, and the patient sweating. On November 4th, he had convulsions every fifteen or twenty nnnutes ; profuse sweating and costiveness. On November 5th, the convulsions were less fi’equent and severe ; still costive, and sweating profusely. On November 8th. the patient had convulsions every thirty minutes, and from that time the convulsions grew less frequent. On the 25th, he was able to sit up in a chair; the use of the muscles of the jaw were natural, and the wounds had healed. He was discharged the service on January 12th, 1833. The case is reported by Acting Assistant Surgeon A. W. Kayes. Leonard is not a pensioner. Foreign Bodies Extracted. — It was not uncommon for bits of clothing, buttons, wire, and other fragments of the soldier’s outfit to be buried in' the wound : Case. — Privuite Garret Lukens, Co. E, 88th Peunsylvaiua Volunteers, aged 40 years, was wounded at Gettysburg, July 1st, 1863, by a conoidal ball, which entered just below the middle of the steruo-cleido-mastoid muscle, and emerged over the sixth cervical vertebra. Ho was, on July 7th, admitted to Satterlee Hospital, Philadelphia. Flaxseed poultices were applied to the wound; tonics, stimulants, and cod-liver oil were administei'ed, and full diet ordered. On August 25th, a piece of blouse was taken from the posterior part of the wound. The patient had severe night sweats, and a tendency to anmmia. On October 20th, he had slight tonsilitis, and stiffness of the neck. He was returned to duty March 24th, 1864. The case is reported by Acting Assistant Surgeon W. J. Grier. Lukens is not a pensioner. Case.^ — Sergeant J. E. Gemniel, 8th New York Battery, was wounded at Fair Oaks, May 31st, 1862, by a musket ball, which entered over the left border of the trapezius muscle, opposite to the sixth cervical vei’tebra, passed upwai'd and inward, and lodged in the superior carotid triangle, immediately external to the trachea. On the reception of the injiuw the ))atient fell from his horse, receiving a contusion of the left arm. He was, on .Juno 4th, admitted to Douglas Hospital, Washington. Simple dressings were applied to the wound. On June 6th, the patient had considerable difficulty of deglutition. An abscess had formed, which was opened, and the ball, with a piece of cloth one inch in length, was extracted, and difficulty of deglutition disappeared. June 20th, there was neuralgic pain in the arm, and impairment of its use. He was discharged the service July 11th, 1862. The case is reported by Assistant Surgeon William Thomson, U. S. A. Gemmel is a pensioner. The Examining Surgeon repoifs that the ball must have severed some part of the cervical plexus of nerves, as there is complete paralysis of arm and hand. The arm is much smaller than it should be, and cannot be used except for very light work. Torticollis. — Many examples of wry-neck will be found among the abstracts of cases, in which some other complication was a more prominent feature. It is the opinion of Dr. Stromeyer* that when the muscles only are injured, in gunshot wounds of the neck, torticollis will not be permanent, and there is no higher authority on this particular suliject. Yet the reports of the pension examining surgeons indicate that distortion of the neck from wounds of the sterno-mastoid is often very persistent. Case. — Private Andrew Burknett, Co. E, 25th Kentucky Volunteers, aged 31 years, received a gunshot wound of the neck and side at New Hope Church, Georgia, May 27th, 1864. He was taken prisoner, and afterward paroled and admitted to the hospital at Camp Chase, Ohio. On February 23d, 1865, he was transferred to the Tripler Hospital at Columbus, Ohio. On admission, the patient was in a debilitated condition consequent upon his long imprisonment, and sufi'ering from a severe hernia. Partial torticollis supervened. He was discharged from service on AprW 10th, 1865. He is not a pensioner. Case. — Private Baltzer Weild, Co. K, 9th Pennsylvania Volunteers, received, at the battle of Bull Run, August 30th, 1862, a gunshot wound of the neck, on the right and posterior portion. The missilt! passed under the trapezius muscle and emerged at the opposite side. lie was, on the following day, admitted to the Mansion House Hosj)ital, Alexandria, Virginia. He was returned to duty on November 18th, 1832. Examining Surgeon G. McCook reported that the patient’s head was bent and could not be moved. Case. — Private Christopher Kallehan, Co. I, 95th Illinois, was admitted, from the field, to McPherson Hospital, Vicksburg, June 15th, 1863, having been wounded the same day by a conoidal ball, which entered the left cheek, ])ussed downwtird and backward, struck the front of the atla.s, and passing forward into the pharynx, was thrown out of the mouth. Simi)lu dressings were applied to the wound. The patient was discharged the service on October 2d, 1863. There was jxu-manent wry neck, and almost perfect deafness. His disability is rated at one-half. Pension Examiner 11. A. Buck rei)orts, February 6th, 1864, that the pensioner suffers from contraction of the left eyelid, deformity of the jaw and face, and deafness. Case. — Private Charles L. Clarke, Co. I, 27th Massachusetts Yolunteers, aged 19 years, was wounded at Roanoke Island, February 8th, 1832, by a musket ball, which entered one inch bidow the lower jaw, .and ))assed through the neck, just behind the windpipe, emerging at the s.ame jtoint on the opitosite side, wounding the larynx and oesopliiigus in its transit. H(i was conveyed to the Craven Street Hospital, New Berne. The patient had severe hsemorrluige, which was controlled by pressure. He was transferred to Boston in April, 1862. He recov^ered, his head drawn to one side, and was discluirged the service on August 18th, 1862. He is not a pensioner. * ilaximm der Kriegsheilkunst, S. 423. 406 WOUNDS AND INJUKIES OF THE NECK. [Chap. Ill, Wounds of the Larynx and Trachea. — No instances were reported of fracture or laceration of the larynx or trachea from blows or falls, as are described by authors ; but about two per cent. (2.2) of the gunshot wounds of the neck that came under treat- ment belonged to this category. In a few, the larynx and trachea were both involved ; in others, the air passages, together with the pharynx or oesophagus, were implicated, as in the case described under the head of torticollis (Clarke, supra). Dr. Derby first cared for this man, arresting the profuse venous haemorrhage by pressure and pledgets of lint. There could be no question that both trachea and oesophagus were wounded, for both liquids and air passed out of both wounds of entrance and exit. The patient remained under my care for several weeks subsequently. He could take fluid nourishment without the use of a stomach tube, and only on a few occasions, when he was sitting upright, was there any inconvenience from his soup or drink passing into the air-passages. The wound of the oesophagus was probably small. It has been impossible to ascertain the sequel of the case. The returns corroborate the opinion of Mr. Blenkins (op. cit. p. 824) regarding the comparative frequency of gunshot wounds of the larynx, exposed as it is by its superficial position, size, and prominence. Aphonia, exfoliation of cartilage, and persistent fistulse were among the consequences of these wounds. The trachea was less frequently injured by small projectiles than the larynx. Gunshot wounds of the organ are oftener observed in the posterior membraneous portion, undefended by cartilaginous rings, than elsewhere. Professor S. D. Gross remarks (op. cit. Vol. II, p. 384) that there is reason to believe that “ this tube possesses the faculty of deflecting bullets.” That missiles are diverted from their course on impact with the trachea, there is ample evidence. Abstracts of a few cases may be cited : Case. — Corporal J. TV. Terry, Co. B, 14th Virgini.a, was wounded at Spottsylvania, May 10th, 18G4, by a conoidal ball, which entered the left side of the neck, passed through the trachea, and emerged parallel to the opposite point of entrance, and again entered the right shoulder anteriorly. On IMay. 11th, he was admitted to the Receiving and Wayside Hospital, Richmond, the air from his lungs passing through the wounds of entrance and exit. On May ICth, the wound of entrance had closed ; hut, he breathed still through the wound of exit. On the 18th, the wounds were suppurating freely ; the patient was able to swallow with comparative ease, the bowels were regular, appetite good, tongue clean ; and there was no pain, except in breathing. On the 20th, he was evidently improving; sat up in bod and said he was feeling very well. About ten o’clock, some intermeddling woman going through the hospital, thinking that she would benefit the patient by renewing the dressing, and, without consulting the Surgeon in charge of the ward, removed the dressing and plugged the wound with cotton, saturated with turpentine. The patient, not being able to speak, was compelled to submit to this cruel treatment, which caused his death on May 20th, 1864, before the woman who did the mischief left his bedside. The case is reported by Surgeon W. F. Richardson, P. A. C. S. Ca.se. — Private Patrick Riley, Co. D, 1st New York Volunteers, .aged 21 years, was wounded at Chancellorsville, M.ay 1st, 1863, by a musket ball, which entered on the left side of the neck, passed behind the trachea, near the cricoid cartil.age, and in front of the oesophagus, laying open both tubes. He was, on May 12th, admitted to Stanton Hospital, Washington. Enemat.a, stimulants, and opiates were administered, .and beef tea injected by an oesophageal tube. Air and nourishment passed through the wound. The patient h.ad a severe cough, and was restless and constip.atcid. May 24th, vomiting occurred; 28th, emaciated from inanition ; capilLary circulation diminished; skin cool and moist; pulse slow and feeble, and the mind w.andering. The patient died on May 29th, 1863. The case is reported by Assistant Surgeon P. C. Davis, U. S. A. Case. — Private John Homer, Co. B, 18th Pennsylvania Volunteers, aged 18 years, was admitted to Douglas Hospital, W.ashington, June 4th, 1862, having been wounded by a missile which entered immediately below the zygomatic .arch, passed downward through the parotid gland into the pharynx, and emerged through the integuments on a level with and one inch external to the thyroid cartilage on the opposite side. June 5th, patient being unable to swallow, and fluids taken into the mouth passing out at the lower orifice, he was nourished by fluids introduced into the stomach through a tube; pus and s.aliva discharged from wound. June 7th, no grave constitutional symptoms; patient still nourished by means of the stomach tube. June 8th, dyspnoea came on about four in the afternoon, and he died seven hours subsequently from apnoea. Case. — Captain Ferdinand Mueller, Co. B, 9th Ohio Volunteers, was wounded at Chickamauga, Georgia, September 20th, 1883, by a conoidal ball, which entered the base of the neck on the right side, passed transversely and obliquely upward, and emerged beneath and mitlway between angle and chin of inferior maxilla, involving the trachea, thyroid, and cricoid cartilages. Sect. II. J WOUNDS OF THE LARYNX AND TRACHEA. 407 and external jugular vein. He also received a wound oftlie slioulder-Joint. He was admitted, on the next day, to the hospital at Chattanooga, Tennessee. There was considerable swelling at first. Ho did well up to the 25th, when secondary hacmori-hage occurred. There was not much loss of blood. On the 2Gth it recurred, and the patient expired before surgical assistance arrived. Aphonia. — In the following cases, however, chronic cough, or complete loss of voice followed gunshot injuries of the larynx or trachea. Dr. Chisolm'^ tells us of similar cases observed in the Southern armies, some requiring the use of a tracheal tube to prevent apnoea : Case. — Sergeant Adolphus Mepsen, Co. F, 103d New York Volunteers, was wounded at Suffolk, May 3d, 1803, by a musket ball, which entered the neck two and a quarter inches to the left of the median line, and two inches above the clavicle, passed through the trachea, and emerged one and a quarter inches to the right of the median line. He was conveyed to the hospital of the 3d division. Ninth Corps. The patient spit up blood freely immediately after the in jury, and lost the power of speech partially. Air made its escape by the wounds. Slight external hannorrhage, and the spitting of blood continued only for a short time. He was transferred to the Chesapeake Hospital, where he was admitted on May 4th. Fourteen days after the reception of the injury the power to articulate began to return, and, on June 7th, the wounds had healed. He was transferred to the Veteran Reserve Corj)s. The case is reported by Surgeon T. H. Squire, 89th New York Volunteers. This soldier is not a pensioner. . Case. — Private Joseph Pearson, Co. F, 64th Illinois Volunteers, aged 18 years, received, at Atlanta, Georgia, July 22d, 1864, a gunshot wound of the neck. A conoidal bullet entered the integuments over and anterior to the larynx and injured the windpipe. He was admitted to the Marine Hospital, Chicago, September 3d, 1864. On the 16th, he was transferred to Camj) Douglas, Illinois. His case is diagnosed as “ aphonia from gunshot wound.” Simple dressings. Pension Examiner John F, Daggett, reports, October 30, 1867, that the pensioner's voice is impaired. Case. — Private James K. Deerner, Co. G, 102 Pennsylvania Volunteers, aged 34 years, was wounded at Cedar Creek, October 19th, 1864, by a conoidal ball, which entered the left side of the neck and passed through the trachea. He was taken to the field hospital, where simple dressings were applied. On October 22d, he was admitted to the Satterlee Hospital, Phila- delphia. By November 1st, the wound had almost healed. Aphonia supervened. Ho was dischai'ged from service on May 15th, 1865. He is not a pensioner. Case. — Private August Beck, Co. D, 54th New York Volunteers, aged 42 years, was wounded at Gettysburg, July 2d, 1833, by a musket ball, which passed laterally through the thyroid cartilage, destroying the upper half and two-thirds of the anterior part, thereby inj uring the chordae vocales. He was, on July 9th, admitted to Satterlee Hospital, Philadelphia. Resj)i- ration was carried on largely through the apertures made by the ball, and when he attempted to speak, the air passed through with a hissing or sibilant sound. His voice was gone, but he could whisper with a strong expiratory effort ; the sound, however, never became hoarse. The edges of the wound were approximated with silver sutures and adhesive plaster, with head Hexed on the chest. Cold water dressings were applied. On September 1st, the wound had entirely healed, but the patient had lost his voice. He was transferred to the Veteran Reserve Corps on September 26th, 1863. The case is reported by Acting Assistant Surgeon W. \V. Keen, jr. He is not a pensioner. Case. — Colonel Morgan H. Chrysler, 2d New York Cavalry, aged 48 years, was wounded at Atchafalaya, Alabama, August 28th, 1834, by a minie ball, which entered at the interclavicular notch of the sternum, just at the point of the right clavicle, injured the trachea and the origin of the sterno-cleido-mastoid muscle, passed to the right and emerged at the superior point of the shoulder. He was sent home, where he was treated for about two months and a half, when he returned to duty. Mustered out of service on November 8th, 1865. A certificate from the Pension Examining Board states that " the right arm can scarcely be extended above the horizontal plane of the shoulder joint. The cicatrix of entrance extends across the clavicular origin of the sterno-mastoid muscle. Pressure upon it causes cough and spasmodic contraction of the laryngeal and pharyngeal muscles, which is visible upon the surface. Similar spasm is caused by loud speaking or by swallowing fragments of food of sufficient size to press upon the trachea in passing through the ocsojihagus. He has attacks, usually nocturnal, of extreme dyspnoea, with a sensation of complete constriction of the lower part of the trachea. These are very transient but often repeated — sometimes without assignable cause, but oftener after fatigue or exposure. This hyper aesthetic condition of the inferior laryngeal nerve seems to depend upon deep cicatricial contraction rather than upon a neuritis, as in the latter case, the length of time which has elapsed since the reception of the wound, nearly eight years, should have led to an implication of the nerve centres, of which there is no evidence. The disability is regarded as total and permanent, and depends both upon the impaired use of the right arm and upon the affection of the throat.” Case. — Corporal Lester Shaw, Co. G, 35th Ohio Volunteers, aged 34 years, was wounded at Chickamauga, Georgia, Sejjtember 19th, 1863, by a conoidal ball, which entered the right shoulder, just behind the acromion, passed inward, injured the cavity of the shoulder-joint, fi-actured the clavicle badly in its external and middle thirds, produced a comminuted fracture of the first rib, passed obliquely upward under the skin, penetrating the neck between the trachea tind the oesophagus, and emerged just in front of the left carotid artery, on a level with the j)omum Adami. The oesophagus was slightly wounded, and the trachea partly severed and badly contused. He was taken to the hospital of the 3d division. Fourteenth Cori)s, where water dressings were applied, and liquid diet given. Severe inflammation ensued, followed by ulceration over tlie middle of the first * “Several instanecs have oecurred in the Ccnfedcrato campaigns, where the trachea has been pcrfur.ated by a sliot, cr the larynx carried away. Such coutractien of the air passage and dilHculty of breathing follows upon this accident, as to force the patient to wear, ]>ennanently, a tracheal tube, to pnitect him from attacks threatening suITucation. In such cases the voice is reduced to a whisper.” CnisoLSi, ojo cit. j). 3t)'J. 408 WOUNDS AND INJURIES OF THE NECK [CllAl>. Ill, rib and beneath tlie clavicle. On September 25th, the patient was sent to hospital No. IG, Nashville, and, on October 3d, to hospital No. 1. Pus was discharged for several months, during which time several spiculm of bone came away. On May 12th, 1864, he was transferred to the Corps d’Affique Hospital, New Albany, Indiana, and, on June 29th, to the Hospital at Camp Dennison, Ohio, whence he was discharged on September 20th, 1864, for expiration of term of service. Pension Examiner E. Mendenhall I’eports that he examined Shaw while home on furlough in February, 1864. The external wounds were healed. 4'he ulceration between the clavicle discharged large quantities of pus, with an occasional spicula of bone. The whole shoulder was very sore, tender, and immovable, and the arm and hand were swollen and numb. The neck was tender on both sides, and he could scarcely speak above a whisper. After a long and tedious process, the wounds all healed. Dr. Mendenhall I'e-exam- ined this patient in April, 1866. He sufl'ered from hoarseness and dyspnoea, which increased on exertion, and was, no doubt, produced by narrowing of the trachea at the place of injury. The arm and shoulder were partially paralyzed ; but the general health apjteared to be good. Wounds of the Pharynx and OEsophagus. — The gunshot wounds of these regions, tliat came under treatment in the hospitals, were .less numerous than those of the more exposed portion of the anterior region of the neck. Complicated hy lesions of the great vessels or nerves, in many instances, such instances often proved fatal on the field. I cite a few cases in which the wound seems to have been mainly confined to these canals. A review of the reports confirms, fully, the opinion of the accurate, reliable, and learned Hennen,* that we can only derive satisfactory explanations of the symptoms in wounds of .the neck, or rational views as to treatment, by considering the region as a “ complete and sympathizing whole.” Yet, for convenience’ sake, where so large a number of abstracts of cases are to be compared, it is well to employ subdivisions : Case. — Private i?. Wiseman, Co. C, 6tli North Carolina Regiment, aged 23 years, was wounded at Winchester, September 19th, 1864, by a conoidal ball, which passed through the oesophagus. He was conveyed to the depot field hospital, W^inchester. Simple dressings were applied to the wound. The patient suffocated from iuternal haemorrhage, and died on September 21st, 1864. Case.— Private Lewis 0. Ritch, Co. C, 106th Pennsylvania Volunteers, aged 20 years, was accidentally wounded at Fairfax Court-house, September 20th, 1862, by a round musket ball and two buckshot. The ball entered below the thyroid cartil.age, passing through the trachea, and lodged in the pharynx, from which it was subsequently extracted. One buckshot fractured the right side of the lower jaw, and destroyed five teeth, and another entered the left side of the neck, a few inches above the clavicle, and lodged, and is still in the neck. He was, on October 6th, admitted to Armory Square Hospital, Wash- ington. Cold water dressings, lotions of lead and opium, and warm fomentations were applied to the wounds, and tonics and stimulants administered. There was much inflammation about the throat, and food could be swallowed only with difficulty ; air passed through the wound in respiration. On October 10th, the wound discharged slightly, but healthy ; on the 15th discharged freely ; patient exhausted, labor! ng under anorexia. On October 23d, inflammation, erysipelatous in character, was increasing, and, on the 26th, extended over the entire head and face. November 2d, the patient was improving, and, on the 6th, the wounds were healing. He was discharged the service on December 15th, 1862. Tiie case is reported by Surgeon D. W. Bliss, U. S. V. Pension Examiner 11. E. Goodman reports, September 1st, 1869, that there is a large depression over the cervical bone, loss of voice, difficulty of breathing, with constant cough. The lungs and heart are normal ; the digestion is bad, and constant care is necessary to prevent inflammation. Case. — Private Jonathan Colgrove, Co. F, 57th Pennsylvania Volunteers, aged 19 years, was admitted to McKim’s Mansion Hospital, Baltimore, on July 5th, 1863, for a gunshot wound of the neck, received at Gettysburg, July 2d, 1863. Tfie missile having entered the right side near the submaxillary triangle, emerged on the opposite side, near the median line, perfo- 1 ating the cricoid cartilage, and wounding the oesophagus. Cold-water dressings were applied to the wound, and a full diet allowed. For some days after the reception of the injury, both air and liquids escaped from the wound. On August 15th, there was partial .aphonia. This man was returned to duty on August 24th, 1863. He is not a pensioner. Paralysis . — Many examples of paralyses, partial or total, resulting from gunshot wounds of the cervical nerves, or of those ascending to the face or descending to unite in the brachial plexus, are found in the reports. A few abstracts may be cited : Case. — Private John P. Crole, Co. F, 27th Michigan Volunteers, was wounded at Poplar Grove Church, Virginia, September 30th, 1864, by a minie ball, which entered two inches above the sternal extremity of the left clavicle, emerging at the superior angle of the left scapula. He was treated in the hospitals of the Ninth Corps until October 5th, when he was admitted to Mount Pleas.ant Hospital, Washington, and discharged on March 20th, 1865. There was partial loss of motion of left arm. He is not a pensioner. * The close and intimate connection of the great vessels and nerves, and of the canals leading to the thorax and abdomen, are. such that separate views of their affections, however they may carry the appearance of minute accuracy along with them, arc more the objects of speculative calculation in the closet than the results of actual experience, and cun seldom be of any j)ractical utility in the held or hospital. Op. cit. b'd ed., p. 3G1. Sect. II.] PAKALYSIS IN GUNSHOT WOUNDS OF THE CERVICAL REGION. 409 Case. — Private Joseph Hoilinger, Co. G, Ctli Maryland Volunteers, aged 22 years, was wounded at Wineliester, Virgini.a, September lOtli, 18G4, by a conoidal ball, which entered about one-half an inch above and slightly to the right of the median line of the thyroid cartilage, and emerged from the top of the left shoulder, three inches above the sj)ine of the scapula and four inches to the left of the spine. He was taken to the hospital of the 3d division. Sixth Corps, and, on September 27th, sent to the hospital at Frederick, Maryland. Simple dressings were applied. On November 18th, he was transferred to the Mower Hospital, Philadelphia, and on January 2Gth, 18G5, to Turner’s Lanfe Hospital. While at Mower Hospital, electricity had been applied, which caused great pain. On admission to Turner’s Lane Hospital, his general health was good; there was ]iartial paralysis of the arm, with slight atrophy; galvanism was applied daily to the arm. On May 24th, he was transferred to IMcClellan Hospital. Friction was applied, and the arm rubbed with liniment. He was discharged from service on June 10th, 18G5, at which time he had recovered from paralysis. He is not a pensioner. Case. — Private William Hunter, Co. F, 5th Maryland Volunteers, received, at the battle of Antietam, Maryland, September 17th, 18G2, a gunshot wound of the neck, the missile entering about an inch and a half below the right ear and emerging a little above the seventh cervical vertebr-a. He was taken to the hospital of the 3d division. Second Corps. On January 14th, 18G3, he was admitted to Carver Hospital and discharged from service on IMarcli 30th, 18G3. Pension Examiner H. W. Owings reports, January 24th, 18G7, that the right arm is almost completely paralyzed. Case. — Private T. D. Pomeroy, Co. E, 68th Ohio Volunteers, received a gunshot wound of the neck at Champion Hills, Mississippi, May 16th, 1863, the ball entering below the right jaw and lodging near the vertebra of the neck. He was treated in field hospit.al until June 24th, 1863, when he was conveyed to Memphis, Tennessee. On July Cth, he was admitted to the City Hospital, St. Louis, aiid transferred to Jefferson Barracks, Missouri, July 24th, 1863, at which time there was partial paralysis of the whole system. He was discharged from service on August 14th, 1863. Pension Examiner Wulliam Ramsey reports, September 29th, 1863, that the spinal marrow has been injured to such an extent as to produce paralysis of the upper extremities, more especially the right arm. His speech was also affected. Case. — Private Sylvester Dcarstyne, Co. F, 44th New York Volunteers, received a gunshot wound of the neck at Bull Run, Virginia, August 30th, 1832. The missile entered at the centre of the right sterno-cleido-mastoid muscle and lodged. He was admitted, on the next day, to Fairfax Street Hospital, Alexandria. On September 16th, he was furloughed for thirty days, and reporting, at the expiration of his leave, to Ira Harris Hospital, Albany, New York, was discharged from service on November lOth, 1862, at which time there was paralysis of the right arm. He is not a pensioner. Case. — William Benson, a seaman attached to the steamer Commodore Perry, was admitted into the Post Hospital at Plymouth, North Carolina, Msiy 1st, 1863, with a gunshot wound of the neck. The missile having entered immediately above the clavicle at the junction of its external and middle thirds, passed backward and emerged near the spine of the scapula, at the superior angle of the bone, injuring, in its passage, the branches of the brachial plexus distributed ovei' the arm and shoulder. Simple dressings were applied. Paralysis of the muscles of the arm and shoulder resulted. He was discharged from service on November 3d, 1863. He is a pensioner. Case. — Private John Hartman, Co. E, 15th New York Heavy Artillery, aged 24 years, was wounded on the South Side Railroad, Virginia, April Isl, 1865, by a conoidal ball, which entered just beneath the angle of the left inferior maxilla, passed downward and backward, and emerged over the spinous ])rocess of the third cervical vertebra. He was treated in field hospital until April 5th, when he was sent to Lincoln Hospital, Washington. On May 23d, he was sent to Summit Plouse Hospital, Philadelphia, whence he was discharged from service on June 15th, 1865. Pension Examiner W. M. Chamberlain reports. May 2d, 1869, that the brachial plexus was probably injured, as the arm is semi-paralyzed and feeble. Case. — Private G. Bowen, Co. D, 51st North Carolina, aged 31 years, was wounded ne.ar Richmond, Virginia, Miiy 10th, 1864, by a conoidal ball, which entered at the top of the sternum and emerged at the internal superior portion of the left sc.apula, passing through the neck. He was admitted, on the same day, to the Chimborazo Hospital, Richmond. An abscess formed near the wound of entrance about one week after admission, which was opened. Cold applications were aj)plied. There was paralysis of the left arm and leg. On May 22d, small abscesses appeared in the leg of wounded side. Death resulted on June 25th, 1864. 'The autopsy revealed both wounds healed ; the track of the wound was found occupied by clotted blood. Case. — Private Patrick Norton, Co. D, 70th New York Volunteers, was wounded at Bull Run, Virginia, August 28, 1862, by a pistol ball, which entered near the right primitive carotid artery, and emerged near the inferior border of the scajtula on the left side. He was admitted, on the next day, to the Presbyterian Church Hospital, Georgetown, D. C. The patient was somewhat exhausted when admitted, but rallied under the use of stimulants. Respiration was easy. Cold water dressings were a])plied and anodynes given. During the night the patient was extremely restless, continually calling for w.ater, and wishing to have his position changed. The pulse was full and bounding. There was paralysis of the upper and lower extremities, consequent upon the severing of some of the nerves involved in the wound. There was also paralysis of the sphincters of the bladder and rectum, the fseces and urine being voided involuntarily. Great irritability of the stomach was a constant symptom, it being impossible for the patient to retain food or medicine for more than fifteen minutes. Involuntary emissions of semen occurred nearly every two hours. The patient finally became so noisy and troublesome that it was necessary to have him isolated. He continued iu this condition until September 16th, when he began to sink, and died on September 20th, 1862. Case. — Private Henry Graff, Co. I, 7th Massachusetts Volunteers, aged 30 years, received, at Fredericksburg, May 2d, 1863, a gunshot wound of the neck, left side, just above the clavicle. He was conveyed to the hospital of the 3d division. Sixth Corps, and transferred to Washington, where he was admitted into the Lincoln Hospital on June 15th. On the 16th, he was transferred to the Camden Street Hospital, Baltimore, where he w.as admitted on the same day. On .Inly 2d, he was trtmsferred to Hammond Hospital, Point Lookout, whence ho was returned to duty on June 14th, 1864. On September 3d, 1864, Examining Surgeon George Stevens Jones stated that a fistulous ojiening existed, and that his left arm was nearly powerless and useless. 52 410 WOUNDS AND INJUEIUS OF THE NECK. [CiiAr. III^ Case.— rrivate F. B. Smith, Co. B, 17th Michigan Volunteers, aged 27 years, received, on May Gth, 1HG4, a gunshot wound of the upper third of the neck, posteriorly. lie was, on May 2r.th, admitted to Campbell Hospital, Washington. The patient had total paralysis of the right hand, and partial of the left. He died on June 2d, 18G4. Case. — Private James Carson, Co. G, 95th Pennsylvania Volunteers, aged 19 years, received, at Spottsylvania, on May 12th, 18G4, a gunshot wound of the neck. The missile, a conoidal ball, entered one and a half inches to the right of the seventh cervical vertebra, passed diagonally through and emerged just below the inferior maxilla, one inch from its angle, carrying away a small spicula of bone, involving the nerves and destroying, to some extent, the deep muscles of the side of the neck. The patient fell paralyzed on the reception of the wound, and was unable to move his limbs for half an hour, but he gradually regained the use of the lower extremities and the left arm, on the following day. He was, on May 25th, admitted to Harewood Hospital, Washington, and, on the 31st, transferred to Philadelphia, where he was admitted into the Convalescent Hospital. Simple dressings were applied to the wound. On June 22d, he was transferred to the Turner’s Lane Hospital, where, on Sei)tember 5th, a small piece of necrosed bone was removed. He was discharged the service on December 9th, 1864, and pensioned. Case. — Private William H. Curtis, Co. A, 78th Illinois Volunteers, aged 28 years, was wounded at the battle of Jones- boro’, September 1st, 1864, by a conoidal ball, which entered the left side of the neck, one inch anterior to the sterno-cleido- mastoid muscle, at a point midway between the sternum and the inferior maxilla, and lodged about the centre of the scapula on the anterior side. He was, on November 26th, admitted to Brown Hospital, Louisville, Kentucky, and thence transferred to Jlound City Hospital, Illinois, December 1st. Simple dressings were applied to the wound. The wounds had healed December 13th ; there was partial paralysis of the arm and hand, and all the muscles of the shoulder were partially atrophied. The patient was unable to raise his hand to his face, and had some constant pain in his shoulder. He was discharged the service March 11th, 1865. The case is reported by Surgeou Horace Wardner, U. S. V. Curtis is a pensioner; his hand is completely disabled and stiff. His disability is total and permanent. Case. — Corporal Ralph White, Co. E, 9th Pennsylvania Reserves, received at the battle of Drainsville, December 20th, 1861, a gunshot wound of the neck. A ball entered a few inches to the right of the fourth cervical vertebra and lodged. The wound healed and he performed duty until the middle of January, 1863 , when he commenced to suffer from severe pain. He was discharged from service March 9th, 1863, and pensioned. Pension Examiner G. McCook reports that there is partial paralysis of the right shoulder, caused by ball pressing on the nerves. Disability one-third. Case. — Private David Campbell, Co. F, 29th Pennsylvania, aged 31 years, was wounded at Gettysburg, June 3d, 1863, by a conoidal ball, which entered the left side of the neck ; passed directly downward through the edge of the trapezius muscle into the cavity of the thorax, where it lodged. He was admitted, on October 25th, to Satterlee Hospital, Philadelphia. Simple dressings were applied to the wound; the ball was unsuccessfully searched for. The transverse process of the fifth cervical vertebra, being found necrosed, was removed. The wound granulated finely, and by November 22d, had almost healed. He was transferred to the Veteran Reserve Corps, December 31st, 1863. Pension Examiner Thomas H. Hope reports, July 16, 1869, that the pensioner complains of frequent shooting pains through the chest and along the left arm to the elbow, the use of which is impaired. On the same day that he received the above injury he was ridden over by the enemy’s cavalry, receiving extensive wounds of the thigh, which ulcerated. The limb is much enlarged. See page 459. Case. — Private Frederick Gening, Co. H, 100th New York Volunteers, was admitted to Ira Harris Hospital, Albany, New Yoi’k, October 4th, 1862, with seven gunshot wounds, supposed to have been received at the battle of Fair Oaks, Virginia, May 31st, 1862. One missile entered midway between the two scapulas over the seventh cervical vertebra, disappearing and wounding or pressing upon the right axillary plexus of nerves. During the treatment of the case one ball was extracted. Ho was discharged from service November 10th, 1862. There was total paralysis of the right arm. Horatio N. Loomis, Pension Examiner, reports. May 27th, 1864, that the right arm was almost useless, and that he suffered pain in right side and chest. Case. — Captain John Foster, Co. D, 111th Illinois Volunteers, aged 35 years, was wounded at Fort McAllister, December 13th, 1864, by a conoidal ball, which entered at the middle of the upper third of the left humerus, ranged upward and inward, passed through the deltoid muscle anterior to the bone, through the axilla, beneath the clavicle at its middle, and thence through the neck, emerging at the posterior edge of the sterno-cleido-mastoid muscle of the right side, wo\inding, in its track, the brachial plexus and destroying sensation in the ulnar side of the arm. He was admitted, on December 26th, to the Officers’ Hospital, Be.aufort, South Carolina, whence he was discharged from service on December 30th, 1864. Pension Examiner \V. H. Castle reports that the pensioner suffers from constant dyspnoea and partial loss of voice. Case. — Private Charles C. Ewer, Co. D, 44th Massachusetts Volunteers, aged 23 years, was wounded while in the act of firing, at Whitehall, North Carolina, December 16th, 1862, by a round musket ball, which entered at the inferior border of the thyroid cartilage, just to the right of the median line, passed backward and outward, and emerged over the right scapula about an inch from its superior angle posteriorly and near its spine. On the reception of the injury the arm fell, and he suffered great pain for about one month, during which time the arm, forearm, and hand were very sensitive, the slightest contact causing intense pain. The power of speech was lost entirely for six w-eeks. The limb was carried at right angles, and sulphate of morphia exhibited hypodermically to relieve the pain. He was admitted to the hospital at New Berne, North Carolina, December 21st 1862. The wounds of entrance and exit healed by February 5th, 1863, and never broke out again. At this date he was transferred to his home in Boston, Massachusetts, where he was treated by Dr. Gay. The pain abated gradually, and in six months he was able to bear some friction with the palm of the hand on .the surface of the limb. Passive motion of the arm, which had become somewhat fixed, was continued daily, with friction, for about a year, when he was able to cany a light cane. He was dischai-ged from the service on May Gth, 1863. H. W. Sawtelle, M. D., reports, under date of November 26th, 1870, “the limb is now normal in size, but the fingers are quite sensitive in cold and damp weather. He states that after much exertion, and promiting and supinating the limb, a sharj) pain is experienced in the thumb and index finger.” Mr. Ewer is a clerk in the Treasury De])artment. He is a pensioner. Sect. II.] HiEMOREHAGE. 411 Case. — Private J. II. McCullough, Co. F, 59tli Alabama Regiment, aged 27 years, was wounded near Ridimond, Virginia, Itlay 16th, 1864, by a conoidal ball, wbicb passed transversely through the neck from the right side, one and a half inches below the thyroid cartilage, perforating the trachea. He suffered from aphonia until June 5th, 1864, when he was furloughed, at which time both orifices were entirely healed. Case. — Corporal Eohert T. Arnold, Co. A, 4th Georgia Regiment, was wounded on May 8th, 1864, hy a conoidal b.all which entered about the middle of the sterno-cleido-mastoid muscle, left side, and emerged at the middle of the right clavicle, wounding the larynx in its course. He was conveyed to the Confederate hospital at Farmville, Virginia. The treatment in the case has not been recorded. The injury resulted in aphonia. He was furloughed on J uly 18th, 1864, for sixty days. On February 2oth, 1865, he was admitted into the Jackson Hospital, at Richmond, Virginia, whence he was returned to duty on February 28th, 1865. Case. — Private William L. Switzer, Co. F, 5th Iowa Volunteers, aged 25 years, was wounded at luka, September 19th, 1862, by a musket ball, which struck the larynx near its centre, just below the left portion of the lower jaw, passed through it and emerged at the edge of the sterno-cleido-mastoid muscle, about three inches below the angle of the jaw; another ball struck near the acromium process of the right shoulder in front, psssed under the upper portion of the humerus, and out about four inches below the head of the bone, near the external edge of the deltoid muscle. He was, on October 19th, admitted to Keokuk Hospital, Iowa. On March 31st, 1863, he could not speak aloud, and probably never would ; he was pale and sickly looking, and had the appearance of a person whose general health was broken down. He was discharged the service on December 20th, 1862. The case is reported by Examining Surgeon Oramel Martin. Case. — Corporal Valentine Stork, Co. L, 5th Pennsylvania Cavalry, received, at Williamsburg, September 9th, 1862, a gunshot wound. The missile entered the right side of the neck, passed under the sterno-mastoid muscle, through the tracliea, and emerged at the left side above the sternum. He was, on September 10th, admitted to Nelson Hospital, Yorktown, Virginia. He was discharged the service on November 30th, 1862. Examining Surgeon G. McCook, by whom the case was reported, states that Stork’s voice was almost suppressed, and his breathing impaired. Case. — Private Joseph Phillips, Co. F, 7th West Virginia Volunteers, aged 30 years, received a gunshot wound of the neck at Autietam, Maryland, September 17th, 1862, the missile entering on the left side under the sterno-mastoid muscle, opposite pomum Adami, and emerging at the superior angle of the scapula. He was treated in field hospital until the 27th, when he was admitted into Satterlee Hospital, Philadelphia. He was discharged from service on November 28th, 1862, at which time the wound had healed; there was loss of vision and entire paralysis of the left arm. The Pension Examining Board at Wheeling, West Virginia, reports. May 8th, 1870, that there is atrophy of the left arm, with partial loss of motion. Case. — Private John A. White, Co. A, 31st Missouri, received a gunshot wound of the neck, right side, at Vicksburg, Mississippi, December 29th, 1862. He was admitted to hospital at Benton Barracks, St. Louis, June 29th, 1863, and was discharged the service on October 22d, 1863, for total deafness. His disability is rated one-half. Case. — Private George Fealce, of Sturdevant’s Battery, was struck by a ball, which passed through the concha of the right ear and emerged near the first cervical vertebra. He was admitted to Farmville (Confederate) Hospital. There ensued entire loss of hearing on the injured side, and the patient suffered from neuralgic pains. Haemorrhage. — Of cases in which primary or secondary htemorrhage was the princi- pal feature, the following may be cited; Case. — Major Richard Banning, 80th Ohio Volunteers, received, at Corinth, October 3d, 1862, a gunshot wound. The missile passed through the neck just in front of the carotid artery. He died on the field, from hsemorrhage, on October 3d, 1862. The case is reported by Surgeon E. P. Buell, 80th Ohio Volunteers. Case. — Private Edward B. Taylor, Co. I, 6th Connecticut Volunteers, was wounded at Fort Wagner, South Carolina, July 18th, 1863, by a fragment of shell, which struck at the base of the neck, tearing open the branches of the* thyroid axis and the jugular vein. He was admitted, on the next day, to Hospital No. 8, Beaufort, where styptics and compresses were applied. Itwas decided that to operate upon him would hasten his death on account of haemorrhage. He died on July 27 th, 1863. Case. — Colonel John J. Mudd, 2d Illinois Cavalry, received a gunshot wound of the neck, in June, 1863, by being fired at fi’om an ambush, near Vicksburg, Mississippi. The missile, a buckshot, entered near the inferior orbital foramen, passed downward and backward behind the angle of the lower jaw, wounding the ]iarotid gland, and lodged deeply in the neck, probably under the sterno-cleido-mastoid muscle. Simple dressings were applied. The wound produced great swelling in the fauces and difficulty of deglutition, with some hajmorrhage from the mouth. He was furloughed, and having returned to duty was subsequently killed in action on the steamer City Bell, on May 3d, 1864. Case. — Sergeant Eugene Wilcox, Co. E, 10th Connecticut Volunteers, aged 30 years, was wounded at Whitehall, North Carolina; December 16th, 1862, by a conoidal ball, which entered just above the right clavicle, and, traversing the neck, ]>assed out immediately below the spinous ])rocess of the seventh cervical vertebra. He was treated in the field hospital until December 21st, when he was admitted into Stanley Hospital, New Berne, North Carolina. Simple dressings were applied, and tonhrs, stimulants, and nutritious, fluids administered. On December 24th, there was external hmmorrhage to a considerable extent, which recun-ed on the 28th. It was decided that operative interference could afford no relief. Death resulted in a few houi's after the recurrence of the hsemoiThage, on December 28th, 1862. The autopsy revealed a wound of one of the imjautant branches of the thyroid axis and of the external jugular vein, with sloughing of the neighboring integument. Case. — Sergeant J. W. J. Junls, Co. D, 28th Jlississippi Cavalry, was wounded at Fr;mklin, Tennessee, April 10th, 1863, by a conoidal ball, which entered oj)posite the thyroid cartilage, at the inner border of the sterno-mastoid muscle, and emerged about an inch and a half to the left of the lower cervical vertebra. He was taken prisoner, and admitted to the hospital 412 WOUNDS AND INJURIES OF THE NECK. [ClIAl’. Ill, at Eraiikliii on tlio smno day. lie lost, in tlio coiirso of tliree liours, pcrliaps two (jnarts of blood, after wldc-li the lia>niorrliage erased. On tlie second day, be was taken with severe chills, which recurred at the rate of two or three a day, followed by high febrile reaction. Death resulted on Ajiril ICtli, 1803. The autopsy showed that the jugular vein had been completely severed. The surrounding tissues were extensively infiltrated with pus and blood, and the divided extremities of the vein contained a large amount of jhis. Case. — Captain Jarvis N.Lake, Co. B, 93d Ohio Volunteers, aged 31 years, was wounded at Missionary Ridge, November 23d, 1803, by a musket ball, which entered the right side of the neck, on a level with the pomum Adami, passed between the juguhir veiti tind carotid artery in a directioti downward and backward, and emerged one inch and a half below and one inch to the right of the last cervical vertebra. He remained senseless for hours, and was supposed to be dead; signs of life appearing, he was conveyed to the field hospital, where he recovered from the severe nervous shock which he had sustained. Severe hsemorrhage occurred. On December 18th, he was admitted into the field hospital, Bridgeport, Alabama. Cold water dressings were api)lied to the wound, and restoratives administered. He was transferred to Nashville on December 22d. Pension Exam- iner E. Mendenhall states, on January 4th, 18G4, that “ the patient’s wounds are healed, but the side of the neck, the entir^j shoulder, and arm of the right side are very sore, swollen, and paralyzed.” On a subsequent examination, the soreness and swelling were gone, and the jiatient could use his forearm and hand ; some of the muscles of the shoulder were atrophied. His general health was good. Case. — Private Joseph Step, Co. I, 40th Georgia Regiment, aged 29 years, received. May 20th, 1864, a gunshot wound. The missile entered just below the angle of the right inferior maxilla, passed through the neck, and emerged at a corresponding point on the left side; the same ball also fractured the left humerusT He was admitted to Institute Hospital, Atlanta, where amj)utation at the upper third of the left arm was performed. The patient was weak from loss of blood; there was considerable constitutional disturbance. Secondary haemori hage occurred from the wounds of the neck on June 7th. The patient died on June 8th, 1864. Case. — Private Big Jim, Co. M, 6th Kansas Cavalry, received, in a brawl on July 4th, 1864, a gunshot wound of the neck, bj' a conoidal ball, which entered above the outer third of the right clavicle, and emerged above the middle third of the left clavicle. He was, on July 4th, admitted to Fort Smith Hospital, Arkansas. Simple dressings were applied to the wound. Secondary hasmorrhage from the common carotid artery occurred on July 11th, which was temporarily controlled by the appli- cation of the solution of persulphate of iron. The patient died on July 12th, 1864. The autopsy revealed an aperture in the carotid, about two lines in diameter’, and about three-fourths of an inch above its origin. Case. — Corporal Jacob Brandt, Co. D, 142d Pennsylvania Volunteers, aged 31 years, was wounded at the Wilderness, May 6th, 1864, by a fragment of shell, which entered at the right side of the face, on a level with the lower margin of the inferior maxilla, and one inch in front of the condyle, passed backward and downward, and emerged between the scapulte over the spinal column. He was, on May 11th, admitted to Armory Square Hospital, Washington. Stimulants were administered, and generous diet ordered. The patient had frequent chills, and all the symptoms of jiyaunia, and was very much exhausted. Secondary hccmori hage, which was slight, occurred on June 3d, from an ulceration of the external jugular vein. He died on June 3d, 1864. The case is rej)orted by Surgeon D. W. Bliss, U. S. V. Case. — Private Alonzo Hoyt, Co. I, 14th Michigan Volunteers, was admitted from the field into hospital No. 1, Nashville, on January 4th, 1863, for a gunshot wound of the neck, received at the battle of Murfreesboro’, on the 3d. The missile had j)assed through the neck, dividing the intervertebral muscles and laying open the spinal cord. He did not seem to suffer much, but on the night of January 14th, secondary hmmorrhage supervened, and, before any assistance could be rendered, he lost so much blood that he died on the evening of January 15th. At the post-mortem, it was found that sloughing of the common carotid artery had taken place. No paralysis occurred, or anything to mark the extent of the injury. He conversed fi’eely up to the moment of his death. The case is reported by Surgeon Edward Batwell, 14th Michigan Volunteers. Few writers on military surgery have failed to remark on the curious manner in which missiles elude the great vessels of the neck, though passing, apparently, in their immediate track. The examples of this description reported were numerous. Dr. Williamson,* 64th British Regiment, suggests an exiilanation of this phenomenon. Erysipelas after Neck-wounds . — The liability of gunshot injuries, especially of this region, to be complicated by erysipelatous action is often noticed in the reports. One or two cases of recovery are appended. Without other complications, this was rarely fatal. Indeed, in healthy subjects traumatic erysipelas is not commonly a very serious affair. Tonics, and especially iron in the form of tincture of the sesquichloride, were usually employed : Case. — Private diaries Guttery, Co. D, 140tb Peimsylvaniq Volunteers, aged 18 years, received, at Spottsylvania, May 12tli, 1864, a gunshot wound of the upper and posterior part of the neck. He was, on May 15th, admitted to Lincoln Hosjiital, Washington, and, on the 18th, transferred to I’ennsylvauia, where he was admitted into the York Hospital, May 21st. Simjile dressings were ajiplied to the wounds. Erysijielas set in, which covered the entire face and scalp. On June 13tb, he was trans- ferred to the I’ittsburgh Ho.sjiital, whence he was returned to duty on September 22d, 1864. *“It is remarkable that the largo ailcrics and veins in the neck should escape injury so frequently in gunshot wounds. This may, in some measure, be accounted for by the structures in tliis retfioii being so loose and movable that they yield and recede before any projectile." WlLLL\JlSON. Op. cit. p. 72. Sect, II.] SLOUGHING AND GANGRENE, AND PY.^MIA. 413 Case. — Private .lolm II. Betts, Co. II, 120tli New York Volunteers, was wounded at Gettjsbur", July 2d, 18G3, by a musket ball, which entered at a point over the scalenus niedius of the left side, one inch above the clavicle, passed through the neck, and emerged at a corresponding point on the right side. He was, on July 5th, admitted to Satterlee Hospital, I’hiladclphia. On admission, the parts were erysipelatous, and the iiatient had some difficulty of swallowing. He stated that after the inception of the injury, he spat blood for several days. Flaxseed poultices were applied to the wound, and perfect rest was ordered. The wounds discharged pus freelj', but the matter burrowed into the supra-sternal fossa, which being emptied, soon granulated, and the wounds healed readily, with some inclination of the head forward fi’om a rigidity of the anterior muscles of the neck. He was returned to duty on September 23d, 18G3. The case is reported by Acting Assistant Surgeon T. G. Morton. The name of this patient does not appear on the Pension List. Another case [Hayes, 6th Alabama) is detailed on page 404. . Sloughing and Gangrene . — Wounds of the neck were seldom affected with sloughing. Perhaps the looseness of the textures was a safeguard against this complication. At all events, the few instances observed were in the region of the denser tissues. One or two abstracts may be cited : Gase. — Private John McCafferty, Co. I, 114th Pennsylvania Volunteers, .aged 23 years, received a gunshot flesh wound of the right side of the neck by a conoidal ball, at Gettysburg, July 2d, 1863. He was taken to the hospital of the 1st division. Third Corps, and on July 7th, sent to Mower Hospitiil, Philadelphia. When admitted the wound was unhealthy .and painful, with a tendency to slough. Cold-water dressings were applied to the wound, with stimulants internally. By July 13th, the slough extended over a surface four inches in length by three inches in width. The patient was very weak, and the pain continued. On the same day a portion of the slough was removed with the scalpel, .and a solution of creasote applied. By July 21st, the appearance of the wound was much improved and granulating. The slough was all cleaned off. The patient continued to improve, and was returned to duty October 224, 1863, at which time the wound had entirely healed. He is not a pensioner. Case. — Private Frank Eastman, Co. D, 6th New Hampshire Volunteers, aged 18 years, was wounded before Petersburg, Virginia, April 2d, 1865, by a fi’ag- ment of shell, which entered near the spinous process of the seventh cervical vertebra and emerged in front of the ear on the right side. He was treated in field liospital, and, on the 4th, transferred, per steamer Cosmopolitan, to Washington, entering Harewood Hospital on the 5th. The wounds of entrance and exit were greatly lacerated, and in a sloughing condition. After the eschars separated, he steadily improved, from the first, without any apparent constitutional disturbance, the wound discharging he.althy pus and granulating finely. On May 15th, he was transferred to Webster Hospital, Manchester, New Hampshire, whence he was discharged from service on July 24th, 1865. Pension Examiner C. H. Boynton reports, November 13th, 1865, that the patient suffers from deafness in the right ear, and pain and dizziness. Thei-e was a daily discharge of matter from the mouth, coming through the right Eustachian tube. He was unable to Labor. The appear- ance of the wounds, on admission, are imperfectly represented in the wood-cut (Fig. 145 ), a reduced copy of aii excellent photograph. PycBmia . — Purulent infection occurred as an occasional sequel of wounds of the neck, but was not a frequent complication. Of the few cases reported in detail, the notes of the autopsies are, unhappily, incomplete. The following memoranda are placed on record: Case. — Private John Gilman, Co. G, 12th New Hampshire Volunteers, aged 31 years, was wounded .at Ch.ancellorsville, May 3d, 1863, by a musket b.all, which grazed the r.amus of the inferior maxilla, near the angle of the left side, and entered the neck above the sterno-clavicular articulation of the right side, and passed to some point not ascertained. He was, on May 9th, admitted to Harewood Hospital, Washington. Cold water dressings were applied to the wound; stimulants were administered, and generous diet ordered. On May 14th, the patient h.ad some cough, expectoration of a yellowish tenacious sputa, and crepitus in the apex of the right lung. On the 15th, he had chills and fever; on the 23d, restless; pulse fre(juent ; slight venous hfcmorrhage. The patient died on May 23d, 1833. The post mortem examinatioiVrevealed an abscess like an egg, in the spleey-, which was eight inches, by four inches wide. Black gangrenous congestion in several patches in the lower lobe of the right and left lungs. The case is reported by Acting Assistant Surgeon Hirshfield. Ca.se. — Sergeant .John Parker, Co. G, 39th New York Volunteers, aged 30 years, received, .at Beam's Station, August 25th, 1864, a gunshot wolmd of the neck. The missile, a conoidal ball, (uitercal over the sterno-cleido-masloid niusch?, on a line with the inferior edge of the thyroid cartilage and lodged, fracturing the fir.st rib. He w.as conveyed to the hospital of th(^ 1st Fig. 185. — Sloughing shell-wound of neck. Vkot. of Surg. Cascs^ A. M. JM., Vol. I, p. 21. 414 WOUNDS AND INJUEIES OF THE NECK. [Chap. Ill, divisfioii, Second Corps, and transferred to Wasliington, where he was admitted into the Lincoln Hospital on August 28th. The ball was removed from near the first rib; stimulants were administered, and nutritious diet ordered. On August 30th, there was a constant discharge of sanguineous liquor from the wound, which was arrested by compression and bandages. The patient was pate and ana;mic; on September 2d, had chills; sallow look; the surface of the body covered with a profuse perspiration. Pymmia supervened, and the patient died on September 13th, 18G4. The autopsy revealed fifty ounces of fluid in the left thoracic cavity; a large abscess in the left lung, and a small one in the right. The case is reported by Acting Assistant Surgeon W. E. Roberts. Case. — Musician Samuel Potter, Co. K, 43d United States Colored Troops, aged 17 years, received, on July 30th, 1864, an accidental gunshot wound of the neck, by a pistol ball. He was, on July 31st, admitted to Summit House Hospital, Philadelphia. Simple dressings were applied to the wound; tonics and stimulants administered, and generous diet ordered. On August 10th, pyaemia supervened. The patient died on August 13th, 1864. The following table is a consolidation, from all the reports received, of gunshot wounds of the neck. The mortality is 15 per centum. But it must be understood that the figures were taken from the casualty lists and regimental field reports, as well as from the returns of the field, and base, or general hospitals. And thus the excessive ratio of mortality is explained, klany cases are included of grave injuries that never came under treatment: Table XVII. Table of Four Thousand Eight Hundred and Ninety-Jive Cases of Gunshot Wounds of the Neek without ICnown Injury to the Cervical Vertebrae. CHARACTER OP WOUND. Cases. Died. Discharged. Duty. Unknown. Gunshot Wounds of the Neck 4789 570 1056 2394- 769 Gunshot Wounds of the Neck, injuring Trachea 41 21 11 8 1 Gunshot Wounds of the Neck, injuring Larynx 30 10 8 2 10 Gunshot Wounds of the Neck, injuring Pharynx 13 7 2 3 1 Gunshot Wounds of the Neck, injuring (Esophagus 10 6 2 2 Gunshot Wounds of the Neck, injuring Trachea and Larynx 4 1 3 Gunshot Wounds of the Neck, injuring Trachea and Pharynx 2 2 Gunshot Wounds of the Neck, injuring Trachea and (Esophagus 2 2 Gunshot Wounds of the Neck, injuring Larynx and Oesophagus 1 1 Gunshot Wounds of the Neck, iniurinn: Pharynx and (Esophagus 1 1 Gunshot Wounds of the Neck, injuring Pharynx and Larynx 2 2 Aggregates 4895 618 1083 2413 781 SlXT. III.] OPEEATIONS ON THE AIR PASSAGES. 415 Section III. OPERATIONS ON THE NECK. The following table presents a numerical exhibit of the principal cases in which operative interference was resorted to on account of injury or disease in ‘the cervical region ; Table XVIII. Table of One Hundred and Thirty-eight Operations for Gunshot Wounds and Surgical Diseases of the Nech. CHARACTER. Cases. Died. Discharged. Duty. Unknown. 29 22 2 4 1 14 8 4 2 6 5 1 2 2 87 12 36 29 10 Affjrreiiates 138 47 45 35 11 Operations on the Air-passages. — Of the twenty cases of bronchotomy reported, six -were operated on because of gunshot wounds, and two of these had a successful issue. The abstracts are appended, — to be followed by those of the operations performed for disease : Case. — Captain John S , 53d Pennsylvania Volunteers, aged 24 years, was admitted to Jarvis Hospital, Baltimore, July 5th, 1863, having been wounded at Gettysburg on July 2d. He states that he received a wound of the neck, which bled so profusely that he had to be carried to the rear, where simple dressings were applied. The hminorrhage continued for some hours, and finally stopped of its own accord. At nine o’clock A. M., on the day of admission, he was found bright, breathing easy, pulse 96, and able to converse without difficulty. There was excessive swelling .about the neck ; the wound had closed, and no emphysema existed. The patient reported that for two diiys air had esc.aped from the wound at each expiration, but now it had entirely ceased. The wound (supposed to h.ave been made by a buckshot) is loc.ated over the centre of the left j)late of the thyroid cartilage, is about one-fourth of an inch in length, and its course is directly backward. Where the shot lodged could not be ascertained, but it must have passed through the larynx. The patient’s symptoms after admission scjon became alarming. He fell asleep in a sitting posture, and dyspnoea was most marked. At twelve o’clock M. his pulse had increased to 116; breathing was more labored; the chest and face were covered with a cold perspiration, and his expression was extremely .anxious — symptoms indicating a critical condition and demanding active steps to be taken. The swelling and aalema around the seat of injury, both internally and externally, were rapidly on the increase ; emphysema had set in, and extended down the chest, especially on the left side, as far as the false ribs. A consultation of surgeons was held, and it was decided to pei'foi-m tr.acheotomy. The instruments wdected for the operation not being .at hand, they were kindly furnished by a distinguished surgeon of Baltimore. A straight incision, commencing over the cricoid cartil.age, was made and carried downward in the direction of the median line for about one and a half inches through the integuments. The thyroid gland being exposed was found greatly distended and infiltr.ated with air, fibrin, and bloody 8lications of nitrate of silver to the glottis, as to render an operation imperative. On January Cth, the patient was etherized and tracheotomy performed by Acting Assistant Surgeon S. W. Langmaid. The operation was simply a longitudinal incision, as low down in the trachea as possible, and the insertion of a silver tube. Beyond the great congestion of the blood-vessels of that part of the trachea involved in the operation no local lesions were observed (the original wound having healed), and the patient’s general condition was good, with the exception of almost complete apnoca from difficult respiration. The operation was followed by instant relief of the dyspnoea, and rapid recovery of health and strength. The wound healed kindly under the application of t(q)id water dressings. On March 26th, the original tube was removed and a double fenestrated canula substituted. A laryngoscopic examination showed great swelling and depression of the epiglottis, effectually preventing observation of the parts below. Direct apj)lication of glycerine and tannin solution by aid of the laryngoscope resulted in restoring the ejnglottis to its normal size and position by March 3Gth, and the j)atient was able to articulate distinctly a few words. He still wore the tube. On July Gth, 18G.3, this man was transferred to Dale Hospital. His naimi is not on the Pension List. Sect. III.] OPERATIONS ON THE AIR-PASSAGES. 417 Case. — Private TV. J. Hindles, Co. H, 6th North Carolina Regiment, aged 30 years, received a gunshot wound at Win- chester, Virginia, September 19th, 1834, the ball entering at the left shoulder, near the spine, and emerging at the symphysis of the lower jaw. He was admitted on the same day to the depot field hospital. On October 1st, ho had become anaemic from repeated limmorrhage. The entire neck in front was distended from diffused clot. Surgeon A. Atkinson, P. A. C. S., performed tracheotomy on occurrence of asphy.xia from pressure of clot on larynx while attempting its removal. He gradually sank from loss of blood and suffocation, impending from diffused clot pressing on trachea, and died on the same day from asphyxia and hmmorrhage. At the autopsy, a diffused clot was found throughout the front and side of the neck, pressing upon the trachea and following in the track of the wound. The transverse processes of the third and fourth cervical vertebrm were found fractured, and the vertebral artery severed. Bronchotomy for Disease. — Six cases of laryngotomy or laryngo-tracheotomy, and eight of tracheotomy for non-traumatic causes were reported. Of the fourteen cases, one of laryngotomy and four of tracheotomy were successful. In six of these cases, the operation was performed on account of cedenia of the glottis : Case. — Private Samuel Frosh, Co. F, 1st Regiment Potomac Home Brigade, aged 21 years, was admitted to Hospital No. 1, Frederick, Maryland, March 24th, 1834, with pleuro-pneumonia of the left side, from which he made a very favorable recovery, and was able to go out, about April 7th. On April 10th, he complained of a sore throat and very great difficulty in swallowing, occasionally strangling on attempting it. There was tenderness on pressure of the larynx and trachea. Nothing but a very slight redness could be seen in the throat. A gargle was ordered, with hop fomentations. On the 12th, his coun- tenance was anxious, inspiration and respiration obstructed but not laborious. On feeling the epiglottis it was found to be cushiony. It was of a yellowish red color, and shone much as if serum were beneath the mucous membrane. The sides of the fauces were not much reddened. (Edema of the glottis was diagnosed. The treatment consisted of incisions, which were thoroughly made, and the application, externally, of tincture of iodine, with inhalation of vapor from warm water. The incisions gave him great relief. At three o’clock A. M., on the 13th, he had an alarming attack of dyspnoea. The incisions were continued, and the epiglottis and arytmuo-epiglottidean folds scarified. At two o’clock P. M., it was decided to operatt?. Assistant Surgeon R. F. Weir, TJ. S. A., cut, with the scalpel, down upon and then through the crico-thyroid membrane and cricoid cartilage and one or two rings of the trachea ; a double trachea tube was inserted, and a warm moist sponge and folded mosquito netting placed over it. Two teaspoonfuls of blood, mostly venous, were lost. The result was immediate relief, to a remarkable degree, of his respiration and suffering. On May 3d, ho was returned to duty ; the tube was no longer worn ; the granulating surface at the site of the incision was very nearly healed; otherwise, he was perfectly well. He visited the hospital on June 9th, 1834, having returned from a re-enlistment furlough. His voice was still rough and hoarse. In attempting to shout, he emitted a squeaking, high-pitched noise. The other five operations of this series resulted fatally : Case. — Private John L , 1st United States Volunteers, aged 23 years, was admitted to Douglas Hospital, Washington, April 7th, 1835, sufiering from an attack of typhoid-pneumonia. He was apparently doing well until the 20th, when he complained of sore throat. On examination, the posterior wall of the phai-ynx was found to be a little reddened, and covered with an abundance of tenacious mucus. At about 2.30 p. M., on the 25th, he was suddenly seized with great dyspncea ; respiration stertorous, countenance livid, and lips blue. There was complete orthopnooa, with great restlessness and jactitation, and entire inability to speak above a faint lisping whisper. These symptoms continued to increase in severity in spite of the administration of an emetic. A consultation was held, and it was decided that the symptoms were those of oedema of the glottis, and that unless relief were promptly afforded the patient would die of suffocation. Laryngotomy was thereupon performed by Assistant Surgeon William F. Norris, U. S. A., by plunging a narrow straight bistoury into the larynx, just above the cricoid cartilage. The relief was almost instantaneous, and there was but little hemorrhage. For want of a trachea tube the lips of the wound were kept apart by bent copper wires, which were carried backward and fastened by a piece of tape behind the neck. During the night the patient took sherry wine and beef tea through an elastic bougie, swallowing small quantities at a time. The following afternoon a trachea tube was introduced into the larynx, which rendered the patient much more comfortable, although it was frequently necessary to remove and cleanse the inner tube, which became, from time to time, plugged by the thick and tenacious mucus which was constantly expectorated. On April 28th, there was a feeling of oppression in the chest ; all the symptoms of bronchitis became more marked, and on the following day he was attacked with pleurisy in the right side. May 1st, well-marked pneumonia of the right side ; respiration rapid ; sputa rusty and frothy. Death resulted from pneumonia on May 4th. A careful dissection was made, and the lungs, laryn.x, and heart removed together. The larynx was pale. The epiglottis, with the edges and upper portion of the glottis, was swollen and oedematous, almost entirely closing the passage. There was a small irregular opening near the vocal .cord of the left side, through which an abscess had evidently discharged. It had previously burrowed down to some extent in the cellular tissue, outside of the larynx, aud had evidently been the cause of the sudden and urgent dyspnoea. There was well-marked hepatization of the lower lobe of the right lung. There was one pint of sero-purulent effusion, and numerous recent adhesions between the parietal and viscera pleura. The pathological specimen is No. 2513, Section I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon William F. Norris, U. S. A. Case. — Private William 11. Schlosser, Co. F, 140th Indiana Volunteers, aged 43 years, was admitted to Douglas Hospital, Washington, February 3d, 1835, with slight bronchitis, which improved up to February Pith, when he was attacked with sore throat and inflammation of the glands of the neck. The symptoms were not severe until the 17th, when great dyspnoea suddeidy set in. The oedematous epiglottis, which was seen and felt, was immediately scarified, with some relief, which, however, was only temporary, and in the afternoon the operation of laryngotomy was decided upon, which was performed by Assistant 53 418 WOUNDS AND INJURIES OF THE NECK, [Chap. Ill, Surgeon William F. Norris, U. S. A. The patient died at the close of the operation from apnoea. At the necropsy the chink of the glottis was found almost closed by oedema of the tissues surrounding it. The epiglottis was also oedeniatous. The bronchial tubes were much injected down to their minute subdivisions. There was a small patch of pneumonic consolidation in the lower part of the left lung. The other organs were healthy. Case. — Private William Carpenter, Co. B, 1st Wisconsin Heavy Artillery, aged 20 yeai’s, was admitted to Harvey Hospital, Madison, Wisconsin, October 10th, 18G4, with an abscess near the larynx. On December 25th, Surgeon H. Culbertson, U. S. V., performed tracheotomy for suflbeation from oedema of the glottis. The patient had nearly ceased to breathe when the trachea was reached, and it was necessary to enter the trachea before the bleeding had stopped. Blood llowed into the trachea, and respiration and action of the heart ceased. A catheter was introduced, and artificial respiration established. A ligature was passed beneath the isthmus of the thyroid gland on each side to prevent further htemorrhage, and a tube introduced. He died on December 2uth, 18G4, from syncope, induced by old heart clots. At the necropsy, an old abscess was found upon the right side of the larynx, which had destroyed the substance of tlve right thyroid cartilage, and lay beneath the mucous membrane and the cellular investment of the larynx, and extended down the trachea two inches from the cricoid cartilage. The rima glottidis was neat ly closed, and would only admit a knitting-needle. The mucous membrane of the trachea was in a state of inflammation, and, opposite the abscess, thickened and indurated in bronchi and bronchioli. The lungs were healthy. Heart generally hypertrophied. The walls were attenuated, and in the right ventricle an old fibrinous deposit obstructed the circulation at the mouth of the pulmonary artery. The latter vessel was empty. The left ventricle was distended with dark grumous blood. The walls of the right ventricle and auricle presented fatty degeneration. Case. — Private James Simonds, Co. A, 3d New Hampshire Volunteers, aged 39 years, was admitted to the National Hospital, Baltimore, February 2d, 1865, with pneumonia in its first stage, extending over nearly the entire surface of the left lung. The respiratory murmur was finely crepitant on admission. Crepitation became more crude on the evening of February 6th. Symptoms of laryngeal inflammation set in, succeeded by those of oedema of the glottis, which continued until the 7th, when the patient was apparently dying. Respiration was excessively labored and ineffective. A blue color pervaded the surface. The pupils were dilated and the extremities cold. The operation of laryngotomy was performed by straight incision between the thyroid and cricoid cartilages. As soon as the operation was performed, all breathing by the glottis ceased except a little valvular cough. The opening was maintained at first by one, and afterwards by two gutta-percha tubes. Warmth returned to the extremities, and a faint color appeared in the face. Death resulted in twelve hours after the operation from pneumonic prostration. Some operators would have reckoned the next case as a success, the patient liaving survived for sixteen days, and died of pneumonitis twelve days after the aperture in the larynx had been closed : Case. — Private J. J. Bryant, Co. E, 1st Texas Cavalry, aged 51 years, was admitted to the Marine Hospital, New Orleans, January 5th, 1865, suffering from oedema of the glottis. The patient became weak and emaciated. On the 25th, the larynx and adjoining parts were greatlj’ swollen. Acting Assistant Surgeon R. W. W. Carroll performed laryngotomy. Immediate relief was afforded by the operation. The oedema gradually subsided, and on the fourth day the tube was removed and the aperture closed, but inflammation of the lungs supervening, death resulted on February 10th, 1865. There were three operations for diphtheria, a successful instance of laryngotomy, and two of tracheotomy that terminated unfavorably : Case. — Private S. G. Inlay, Co. K, 180th Ohio Volunteers, aged 30 years, was admitted to the 3d division hospital, Alexan- dria, Virginia, February 21st, 1865, with diphtheria. On March 5th, he was nearly asphyxiated. Assistant Surgeon W. G. Elliott, U. S. V., performed laryngotomy. Simple dressings were applied. He recovered, and was discharged from service J une 14th, 1865. Case. — Sergeant James W. Sutherland, Co. D, 1st Maine Volunteers, aged 24 years, received a gunshot wound of the right thigh, at Cedar Creek, Virginia, October 19th, 1864, which fractured the femur just below the trochanter major. He was treated in the field, and, on October 24th, sent to Jarvis Hospital, Baltimore. The fracture was an exceedingly' obstinate one, owing to the exterior injury caused by the ball. He became greatly emaciated and broken down, but after several months the fracture united by the use of Smith’s anterior splint, a large amount of j)rovisional callus being deposited. From this time he did well, and improved rapidly under the use of tonics, stimidants, and good diet ; but there were several sinuses which communicated externally, and were still dischai-ging a considerable amount of pus. On the morning of May 24th, 1865, he complained of some soreness of the throat, but symptoms of diphthei’ia Avere not specially marked, there being no traces of membrane whatever. About 10 o’clock P. M., the same day, the nurse Avas awakened by the groans and efforts of the patient to breathe. When medical attendance, Avhich Avas close at hand, reached him, he Avas breathing stertorously ; his tonsils Avere so much SAVollen as to nearly close the glottis and fauces, and the posterior nares Avere covered Avith diphtheritic membrane. Measures Avere at once resorted to for his relief, but Avithout efl'ect. About 12 o’clock P. M., an operation Avas deemed necessary, and tracheotomy Avas performed by Acting Assistant Surgeon F. P. Foster, Avhich seemed to give relief for a time; but he soon relapsed and gradually greAV Avorse, until death, Avhich occurred about 4 o’clock A. Ji., May 25th, 1865. At the neci’opsy the tonsils Avere found greatly enlarged, and the larynx and posterior nares covered Avith diphtheritic membrane, Avhich extended a considerable distance doAvn the trachea. Case. — Private Clement Dennison, Co. E, 32d Maine Volunteers, aged 17 years, Avas admitted to the hospital at Fort Wood, Ncav York Ilarboi’, October 29th, 1864, suffering from inflammation of the tonsils, Avith diphtheria. The constitutional condition of the patient Avas bad. On November 1st, Acting Assistant Surgeon Frederick D. Sturges performed tracheotomy, Avith but little loss of blood. The neck being short and much swollen, the operation Avas quite difficult. Death resulted, November 2d, 1864, from exhaustion. Sect. III.l OPERATIONS ON THE AIR-PASSAGES. 419 There were two successful operations for simple laryngitis : Case. — Private Martin Bowen, Co. K, 149th Pennsylvania Volunteers, aged .31 yeai-s, was admitted to Lincoln Hospital, Washington, October 24th, 18C3, with pneumonia of the lower lobe of both lungs. On November 24th, asphyxia set in. Ether was administered, and Acting Assistant Surgeon W. E. Peck performed tracheotomy. One small vessel was ligated. About half an ounce of blood was lost. Tonics, stimulants, and nutritious diet were given. He gradually improved, and recovered, with the exception that he still had to wear the tube. He was transferred, on August 12th, to the hospit.al at Whitehall, Pennsylvania, and discharged from service June 26th, 1865. Case. — Private Alfred Newcomer, Co. H, 7th Michigan Volunteers, was admitted to Bellevue Hospital, New York City, suffering from laryngitis, contracted, by exposure, while convalescent from typho-malarial fever. Tracheotomy was performed. A few houi's after the operation the pulse was 160, small and very weak ; great irritation of the larynx, causing almost constant coughing. Stimulants and small quantities of beef tea were given. He soon commenced to improve, and in two weeks was able to sit up, and in four was walking about. He could breathe (juite free through the tube, but it was found that it could not be removed. Discharged from service about the middle of October, 1862. Examiuei' J. A. Brown reported, March 9th, 1865, that respiration is entirely performed through the cannula. Disability three-fourths and increasing. There were three cases in which the operation was practiced for threatened asphyxia from tonsillitis or abscess of the tonsil. One resulted successfully : Case. — Private Tajdor Misinger, Co. H, 130th Indiana Volunteers, aged 17 years, was admitted to Hospital No. 1, Nashville, Tennessee, April 3d, 1864, suffering from tonsillitis. On May 1st, 1864, spasm of the glottis set in. The patient became asphyxiated. Assistant Sui’geon Robert McNeilly, 19th Ohio Volunteers, performed the operation of tr.icheotomy, dividing the second and third rings, and inserting a tube. Respiration was established in thirty seconds after the operation. The tube remained twelve hours. On June 25th, 1864, the wound had healed entirely, and the patient was returned to duty. Case. — Private Elias E. Terry, Co. M, 2d New Jersey Cavalry, was accidentally wounded at Memphis, Tennessee, April 2d, 1864, by a carbine ball, which fractured the second toe of the right foot. He was admitted on the same day to Adams Hospital, Memphis, where chloroform was administered, and the toe amputated by lateral flap method. Soon after the operation he was attacked with chills, which yielded to quinine. On April 17th, measles supervened, followed by intense tonsillitis and extreme dyspnoea. On April 21st, Surgeon J. G. Keenon, U. S. V., performed lai'yngotomy. He died seven hours after the operation from asphyxia. The necropsy showed exteirsive inflammation of the larynx, bi'onchi, and trachea. The lungs were much engoi’ged. Case. — Private Nelson Young, 2d Battery, 1st Maine ^Mounted Artillery, aged 23 years, received a slight gunshot wound, at Antietam, Maryland, September 17th, 1862. On October 16th, he was admitted to the hospital at Frederick, complaining of a sore throat. On the 29th there was slight swelling of the right tonsil, which became extended. Inflammation set in on the next day. Astringents were ordered. During the night of the 30th a large abscess burst, and he spat up pus. At 9.30 P. M., October 31st, Acting Assistant Surgeon Redferu Davies was suddenly called to attend him, and found his pulse feeble and too rapid to be counted. Respiration was excessively labored and quick, and had been so for one-half hour. The veins of the head and neck were turgid. On pulling out the tongue by the artery forceps respiration was relieved. The tongue was black, partly from the tincture of muriate of iron, and his lips were dark. As the symptoms grew more urgent, the skin and the crico-thyroid ligament were divided at one incision. The haemorrhage was slight, and the respiration immediately relieved. A little froth issued from the opening; he also breathed by the opening. The pulse immediately fell to about ninety-six, and the lips became almost natural. Finding that he respired easily through both mouth and opening, no tube was used. At 11 P. M. Dr. Davies was again summoned. The symptoms had reappeared. A triangular portion of the crico-thyroid cartilage was removed. No hasmorrhage followed. Respiration gradually declined, and at 11.30 P. M. he died. At the autopsy, twelve hours after death, the tonsils were found to be ulcerated, the right one especially, which was deeply ulcerated and still contained some pus. The uvula was thickened by effusion of lymph, and ulcerated on the right side. The epiglottis was erect, hard, and thickened by effusion of lymph underneath the mucous membrane. The arytaeno-epiglottidean folds were much thickened, especially on the right side, which was considerably above the level of the left. The opening of the sacculus laryngis was entirely closed by the effusion above. Several small patches of false membrane by deposit of lymph were found above the vocal cords, especially on the left side ; none below. The mucous membrane of the trachea and bronchia was deeply congested, but without ulceration, effusion, or deposit. Excision of Tonsils for Disease. — Only two instances of this operation are recorded : Case. — Private John K. Orlup, Co. D, 1st Illinois Light Artillery, aged 20 years, was admitted to Desmarres Hospital, Chicago, Illinois, October llth, 1864. The right tonsil was considerably enlarged, and greatly obstructed the isthmus of the fauces. By May 12th, 1865, the tonsil had become hypertrophied and dense. Surgeon J. S. Hildreth, U. S. V., excised the right tonsil. His breathing became easier and general health greatly improved. He was discharged from service May 25th, 1865. Case. — Private Milton Scott, 24th Ohio Battery, aged 21 years, was admitted to Desmarres Hospital, Chicago, Illinf)is, October 28th, 1834, suffering from double otorrhcea. The tonsils became largely hypertrophied, closing at least three-fourths of the isthmus of the fauces. On January 28th, 1865, Surgeon J. S. Hildreth, U. S. V., excised both tonsils. Little itiflam- mation followed. The wound healed rapidly. He was discharged from service June 26th, 1865. His hearing and general health were considerably improved. Ligations. — Twenty-nine cases of ligations for gunshot wounds of the neck were reported. A few will be cited in detail. The first six are of the primary carotid ; Case. — Corporal eJ. W. Bohinson, Co. C, 27th Georgia Regiment, aged 21 years, was wounded .June 19th, 1864. A musket ball entered the muscles of the neck, just external to the spine, on the left side, passed downward, wounded the internal 420 WOUNDS AND INJURIES OF THE NECK. [Chap. Ill, carotid artery, and probably some branch of the occipital. He was conveyed to the Washington Street Hospital, Petersburg, Virginia, where the left common carotid artery was ligated in the superior triangle. On July 2d, the hmmorrhage recurred. .July 3d, the ligature came away ; the artery was re-ligated below the omo-hyoid, but the haemorrhage still continued, though in diminished quantity, until July 5th, when death occurred. Case. — Lieutenant William Fisher, Co. A, 09th Pennsylvania Volunteers, was wounded at Petersburg, Virginia, October 7th, 1864, by a conoidal ball, which entered two inches behind the angle of the left inferior maxilla, and lodged beneath the integument, near one of the cervical vertebrae, severing the facial and carotid arteries. He was conveyed to the hospital of the 3d division. Second Corps. He was much exhausted from loss of blood. Beef essence and brandy were administered. On October 9th, Surgeon William B. Reynolds, 2d U. S. Sharpshooters, ligated the left common carotid artery below the omo-hyoid muscle. Death resulted in twenty-six lK)urs after the operation. Case. — Lieutenant Charles Debolt, Co. D, 82d Ohio Volunteers, received a gunshot wound of the neck .at Bull Pasture Mountain, Virginia, May 8th, 1882. The missile entered the triangular space formed by the sterno-cleido-mastoid muscle and the larynx, and passed backward and downward along the spine. Surgeon J. Y. Cantwell, 82d Ohio Volunteers, who reports the case, says : “There was but little haemorrhage at the time the wound was received, and considering the locality and extent of the injury, he seemed to be doing rem.arkably well up to the 15th d.ay. On the night following that day he had an attack of secondary haemorrhage that very nearly proved fatal before I could reach his bed. I found him in a state of syncope and pulseless at the wrist. The orifice was immediately filled with lint, saturated with a solution of persulphate of iron, the common carotid artery being compressed at the same time. This completely arrested the bleeding. After watching him until daylight, at which time his pulse and consciousness had returned, I carefully cut down and exposed the common carotid artery, when I ascertained that the haemorrhage was caused by a slough in the coats of the external carotid, so near the bifurcation that it could not be ligated ; hence the ligature was applied upon the common carotid.” The case progressed well to all appearances for six weeks, but suddenly terminated fatally. At the necropsy, a collection of matter was discovered in the locality of the right kidney. Case. — Private Hollis Hutchins, Co. I, 25th Ohio, aged 25 years, was wounded at Pocotaligo, South Carolina, December 9th, 1864, by a conoidal ball, which entered the chin, fractured the inferior maxillary bone, and emerged at the back of the neck. He was transferred, on December 11th, per steamer Cosmopolitan, to Beaufort, South Carolina, entering the 1st division hospital on the 15th. On the 18th, a violent hiemorrhage occurred from the mouth, which was supposed to proceed from the lingual artery, and left him very much exhausted and almost pulseless. Acting Assistant Surgeon S. Hendrickson ligated the common carotid artery just above the omo-hyoid. The patient rallied after the operation, and continued to gain strength until December 27th, when haemorrhage occurred from the trunk of the carotid and the internal jugular vein. He died on the same day. The necropsy showed an organized clot below the ligature; above the ligation no clot had formed, and the coat of the internal jugular vein had sloughed away. Here we have another of the numerous examples of recurrent hsemorrhage from the distal end of the divided or ligated artery. There was an occlusive coagulum on the cardial side of the ligature, — none on the cranial side. In treating of haemorrhage from wounds of the extremities, there will be ample opportunity of demonstrating the soundness of the views of Guthrie on hsemorrhage, and of furnishing exam- ples of the happy results following the teachings of that great surgeon regarding the management of bleeding arteries : Case.— Private Daniel Shockey, Co. I, 101st Indiana Volunteers, aged 22 years, was wounded at Chickamauga, Georgia, September 20th, 1863, by a round musket ball, which entered the face about an inch from the corner of the mouth, passed downward and back- ward across the upper part of the neck, badly fractured the lower jaw in its passage, and was extracted near the transverse process of the third cervical vertebra. He was taken prisoner .and treated in a Confederate hospital. On September 25th, hemorrhage occurred to the amount of a quart, recurring on the 30th. Three other hemorrhages, of October 6th, 9th, and 10th, respectively, so reduced the strength of the patient that the common carotid was ligated. The ligature separated October 29th. He was paroled in April, 1864, and sent to Baltimore, entering Jarvis Hospital on the 18th. He recovered, and was transferred to Camp Parole, Annapolis, May 11th, 1864, and mustered out June 24th, 1865, as coi’poral. Case.— Private G. W. B , Co. G, 42d Virginia, aged 25 years, was .admitted to hospital at Frederick, Miiryland, for a gunshot wound of the neck and face received at Gettysburg, July 3d, 1863. There was secondary haemorrh.age to the extent of twelve ounces, on July 9th, from the external carotid artery. The common carotid was ligated three-quarters of an inch below the bifurcation, on July 10th. IIcEmorrhage did not recur. The patient died July 13th, 1863. A wet preparation of the ligated artery was contributed to the Army Medical Museum, with the history, by Assistant Surgeon E. F. IVeir, U. S. A., and is No. *3969 of the Surgical Section. It is represented in the adjoining wood-cut. Fig. 186. — Gunshot wound of external carotid. Spec. 3969, Sect. I, A. Jl. M. Tabular Statement of Fifteen Ligations of the Common Carotid Artery for Gunshot Injuries of the Neele. Sect. III.] LIGATIONS 421 422 WOUNDS AND INJURIES OF THE NECK. [Chap. Ill, lAgation of Subclavian. — But a single instance of deligation of the subclavian for gunshot wound of the neck is recorded. It was an unsuccessful case, in which a single ligature was placed, outside of the scalenus, on the left side, for secondary bleeding ; GitAVES, H., Private, 5th Pennsylvania Cavalry. Gunshot wound of external edge of sterno-cleido-mastoid muscle, left side, about two inches above clavicle. Ball lodged. Wounded October Cth, 1864. Ilsemorrhage occurred December 14tb, 1864. Left subclavian artery ligated in third portion by Assistant Surgeon W. E. Day, 117tb New York Volunteers, December 16th. Died December 18th, 1864. A number of examples of ligations of minor trunks were also reported. When both ends were tied recovery ensued, and the other cases resulted unfortunately : Duttox, a. H., Colonel, 21st Connecticut Volunteers. Gunshot tvound of right side of neck. Ball fractured the lower maxilla and passed through the larynx, May 29th, 1864. Ilmmorrhages occurred May 31st and June 2d. Facial artery ligated at entrance of wound, June 2d. Died June 4th, 1864. Bakrick, T., Corporal, 44th New York Volunteers. Gunshot wound left side of neck, July2d, 1863 ; ball lodged. Ball extracted. Haemorrhage occurred July 2l6t. Suprascapular artery and two or three branches ligated on the same day. Recovered August 15th, 1863. Adzer, L. C., Private, Co. K, 9th Louisiana Regiment, aged 20 years, was wounded at Monocacy Junction, July 9th, 1864, by a oonoidal ball, which penetrated the neck, severing the occipital artery. He was admitted on the same day to the hospital at Frederick, Maryland. On July 19th, secondary hmmorrhage to the amount of sixteen ounces occurred, and on the next day Surgeon C. H. Todd, C. S. A., ligated the occipital artery in the wound; both ends were secured. He recovered, and was transfen-ed to West’s Buildings Hospital, Baltimore, August 5th. Transferred to Fort McHenry for exchange, November 19th, 1864. Holeiday, D., Sergeant, 26th Pennsylvania Volunteers. Flesh wound of left side of neck, July 2d, 1863. Hremorrhage occurred July 25th, and recurred on the same day. Branch of occipital artery ligated in wound, July 25th ; both ends tied. Recovered May 3d, 1864. Potter, J. H., Private, 15th Massachusetts Volunteers. Gunshot wound of left posterior triangle of neck, June 18th, 1864. Hasmorrhage, July 13th, 1864. One end of superficial cervical artery ligated, in wound, on the same day. Recovered September 23d, 1864. A successful instance was reported of ligation of the internal jugular vein, a subject that has been exhaustively discussed since the conclusion of the war, by Dr. Samuel W. Gross,'*’ late Staff-surgeon of Volunteers : Case. — Private William Seymour, Co. G, 57th New York Volunteers, aged 19 years, was wounded at the Wilderness, May 5lh, 1864, by a conoidal ball, which entered just below the lobulus of the left ear, and passing obliquely downward and forward, emerged one inch above the sterno-clavicular articulation of the light side, external to the stei-no-mastoid muscle ; the missile then struck the subclavian region at the external end of the middle third of the clavicle, and glanced off’ along the arm without touching it. He fell unconscious on the reception of the injury ; fifteen minutes after which, he walked to the rear assisted by a comrade. He had considerable haemorrhage, which ceased spontaneously. He was admitted to the hospital of the 3d division. First Corps. Cold water dressings were applied to the wounds, and beef tea administered, ivhich partly escaped through the wound of exit, giving evidence of injury of the pharynx. He was transferred to hospital via Frederickslmrg and Belle Plain ; the mode of conveyance being an army wagon, the jolting of which caused a slight ha;morrhage, which he expectorated per orem ; he also stated having expectorated a piece of meat one inch in length. He was, on May 11th, admitted to Douglas Hospital, Washington." Cold water dressings were applied to the wounds, and the patient was fed through gum- elastic bougies, and injections anum of beef tea for four days, at the end of which he was able to swallow milk with ease. He gradually improved until May 19th, when he had a secondary haemorrhage from the mouth, amounting to seven ounces of blood. On May 20th, he bled one ounce; 26th, four ounces; and on the 27th, a venous haemorrhage occairred, which was arrested by compression. On the 29th, haemorrhage recurred, amounting to two ounces of blood ; and again on the 30th, to the amount of four ounces; after which it was thought advisable to ligate the carotid artery. Assistant Surgeon William Thomson, U. S. A., made an incision for the artery, which was searched for a long while, but found to be obliterated. From that time no haemorrhage ocem-red, and the patient rapidly recovered. On June 10th, the wound of entrance was entirely closed, and that of exit granulating finely. He had lost the power of the right arm, and for a long time had complete aphonia. The wound had an excrescence not unlike cauliflower, which was daily decreasing in size. He was transferred to Turner’s Lane Hospital, Philadelphi.a, on September 11th. On his admission, the wounds had closed; sensation and motion feeble throughout the right arm; neck had only one-foui-th range of movement ; the sense of touch was lost from the chin to the external angle of the right eye, and lessened on upper neck; analgesia was more or less complete in these ])arts; loss of gustation of the right side of the tongue, pain and sense of temperature limited by median line. Very far back there seemed to be considerable sensa- tion, motion seemed good on the right side, and the left side was paralyzed as to motion entirely. Deglutition was imperfect; the voice nearly perfect ; appetite and digestion good. On October 10th, the face had recovered sensation ; taste not perfect ; GKOBS, (S. W.) On Wounds of the Internal Jugular Vein, in Amcr. Jour, of Med. Sci., 1867, Vol. LIIl, pp. 17, 305. Sect, III.] H^IORRIIAGE AND LIGATIONS. 423 tact and pain still absent. On the 20tli, there was seme feeling in the tongue, but no motion on the left side. He was returned to duty on December 9th, 1804. On May 2d, 1866, Examining Surgeon E. Winslow reports that Seymour’s wounds had healed externally ; but the trachea was constantly dischai-giiig jius by coughing, and was hoai’se, and his light arm weak. Tlie successful case, in which ligatures were placed above and below a puncture of the internal jugular, made by the operator in extracting a ball [ante p. 397), and the two fatal cases of gunshot wounds of the jugular treated by cold applications, compression, and position (pp. 411, 412), will not have escaped the reader’s attention. I fully agree with Dr. Gross, that this subject has received less attention from surgeons than it merits, and should enlarge upon it here, were it not preferable, in order to avoid repetitions, to defer its consideration to a separate chapter on Hceinorrhages. Grouping the ligations of the large vessels of the neck,* performed on account of gunshot wounds of the face or of the neck, we have a total of seventy-six ligations of the common carotid, with a mortality of 78.6 per cent. The exhibit is yet more deplorable than that of the preliminary report in Circular 6, S. G. 0. 1865, which gave, for forty-nine cases, a fatality of 75 per cent. It will furnish M, Ldon Lefort {Gaz. Hehdom. de Med. et de Chir., Paris, 1867) an additional argument against the performance of this operation for traumatic causes, unless the injury involve the main trunk itself, and a ligature can be placed above and below the point of injury. Nowhere else, not even in wounds of the fore-arm or legs in which the brachial or femoral may have been tied, does the operation of Anel appear to greater disadvantage. Tying the common trunk for injuries of the smaller vessels of the head or neck is an operation based on a fallacious interpretation of the ana- tomical and physiological relations of the region. Nothing that is not corroborative of Guthrie’s admirable suggestions is found in the preceding cases. If the indolent or timid surgeon, who, to control bleeding from minor branches of the carotid, prefers to stuff the wound with styptics, or to perform the easy operation of tying the common trunk, rather than to seek in the difficult anatomy of the maxillary and thyroid regions, to place double ligatures at the bleeding point, he may temporize, or may associate his name with the necrology of ligations ; but if his patient recover, it will generally be found to be under circumstances in which the surgeon’s operative intervention was uncalled for.*}* The subject of gunshot wounds of the nerves of the neck, briefly illustrated on p. 408, et seq., by a series of concise abstracts, has been thoroughly and ably discussed by Acting * See Ssnxif, (St.), Ligature of tJie External and Internal Carotids^ for Uaimorrhages of the Face and NS OF THE SPINE. [Chap. IV, fever. The expectoration of blood and mucus continued about twenty-four hours, becoming gradually less. On the 5tb, the fever had somewhat abated, and he e.xpressed himself as feeling comfortable. On the Glh, he was transferred in an ambulance, over a very rougb corduroy road, to the hospital steamer Woodford. A few hours after his transfer, he became delirious, and died on the morning of .Tune 7th, 1863. Al the autopsy, the ball was found to have passed upward through the transverse process of the fourth, and lodged in the canal opposite the third dorsal vertebra. The pathological specimen is No. 1630, Section I, A. Itl. JI., and was contributed, with a history of the case, by Surgeon James Roberts, Mississippi Marine Brigade. Case. — Private Alexander L , Richardson’s Partizan Cavalry, aged 18 years, was wounded at Warrenton Junction, Virginia, May 2d, 1863, by a small conical ball, which entered at the lower third of the scapula at its inner edge, passed obliquely downward and to the left, and lodged in the thorax. He was admitted, on the next daj', to the Mansion House Hospital, Alexandria. On admission, he was found to have paraplegia and complete loss of sensation of all parts of the body below the fourtji dorsal vertebra. Stimulants and tonics, with nourishing and sustaining diet, were given. On May Pith, pneumonia of the left lung set in, which rapidly passed into the third stage. His tongue was clean and aj)petite tolerably good, but bis pulse was frequent and feeble. An expectorant was given, with an anodyne at bedtime. By May 20th, a cavity had formed in the lower portion of the left lung containing fluid. His appetite and strength were diminishing. On the 22d, several gangrenous spots appeared on the lower extremities. His urine and faeces passed continuously and involuntarily, the urine displaying the turbid appearance and strong ammoniacal odor so characteristic of lesions of the sjtinal cord. He continued to grow worse and died on May 27th, 1863. At the autops}’, the lower and part of the upper lobe of the left lung were found entirely destroyed and converted into sanious fluid, of which there were found three pints in the cavity of the pleura. The ball was found to have passed oblicpiely downward and fortvard, and lodged in the body of the fourth rib, fracturing, in its course, the spine of the fourth dorsal vert(;bra. The spinal cord at this point was found softened and disintegrated. The pathological specimen is No. 1600, Section I, A. M. M., and was contributed, with a history of the case, by Surgeon Robert Reyburn, U. S. V. Case. — I’rivate Oliver A. N , Co. B, 13th New York Cavalry, aged 21 years, was wounded at Aldie, Virginia, July 0th, 1884, by a couoidal ball, which entered the right side below the nipple and lodged. He was treated in the field, and, on July 13th, sent to the 3d division hospital, Alexandria. On July 17th, gangrene appeared in the wound. Creasote wms applied. Stimulants, anodynes, and tonics were administered, and nutritious diet given. Death occurred on July 23d, 1864. The autopsy revealed a fracture of the fifth rib, ulceration of the lower and middle lobes of the i-ight lung, and the ball imbedded in the fourth dorsal vertebra. The pathological specimen is No. 3333, Section I, A. M. M., and w'as contributed by Surgeon Edwin Bentley, U. S. V. Among the specimens of gunshot wounds of the fifth dorsal are found examples of balls lodged in the body, penetrating the pleural cavity, perforating the lung, carrying foreign bodies before them into the substance of the lung, and causing effusions into the pleural cavity. Tlie fifth observation will be remarked, because of the long, interval between the reception of the injury and the fatal issue, when the bullet had traversed the spinal canal : Ca.se. — First Lieutenant F. F , of Mosby’s command, was admitted into the field hospital at Sandy Hook, Maryland, September 5th, 1864, with a gunshot fracture of the upper third of the right arm. There was no wound of exit. He died on September 20th, 1864, from i)neumonia and secondary haemorrhage. At the autopsy, the track of the ball was sbown to have been in the long axis of the ami and down the chest. The pathological specimen is No. 3515, Section I, A. M. M., and shows portions of the dorsal vertebrie, with a pistol ball firmly imbedded in the body of the fifth, nearly the whole of which is shattered. The specimen is interesting from the fact of the injury not having been suspected during life. It was contributed by Acting Assistant Surgeon J. Younglove. Case. — Private Lewis N , Co. G, 5th AVisconsiii, aged 20 years, was woundecl in the left chest and left leg at Peters- burg, Virginia, April Cth, 1865. He was taken to the hospital of the 1st division. Sixth Corps. On April 16th, he was transferred to the 1st division hospital, Annapolis ; on May 10th, to the 2d division hospital; on May 23d, to Jarvis Hospital, Baltimore, and, on July 24th, to Hicks’ Hospital. When admitted, the wound discharged large quantities of foetid pus, evidently from the cavity of the chest. Tonics and stimulants were administered, with extra diet. The wound closed up, the ball remaining. Patient gradually failed. Emaciation was extreme, he being reduced almost to a skeleton. Death resulted on September 30th, 1865. At the autopsy, a conoidal ball was found to have entered at the middle of the posterior fold of the axilla, and passed inward and downward, and slightly backward, lodging between the laminse of the fourth and fifth dorsal vertebrffi, the apex of the ball entering the spinal canal, but not ])ressing ujioii or interfering with the theca. The ))leural sac had been opened between the angles and heads of the fourth and fifth ilbs, left side. Outside of this point of opening, the callus had formed an arch between the angles, so that the finger ()assed over a smooth surface in approaching from the outside the pohit of ojiening of the pleura. The pathological specimen is No. 3171, Section I, A. M. M., and was contributed by Surgeon Thomas Sim, U. S. V. Case. — Private George H. C , Co. H, 64th New York Volunteers, aged 17 years, was wounded at Petersburg, Virginia, Mai'ch 25th, 1885, by a conoidal ball, which entered midway between the centre of the left clavicle and the sterno- cleido-mastoitl muscle, passed inward and backward, grazing the posterior portion of the upper lobe of the left lung, passed through the bodies of the third, fourth, and fifth dorsal vertebrm, and was found lying loosely on the sixth rib, right side. He was treated in the field hospital, and, on the 30th, was sent to Lincoln Hospital, Washington. Tonics and stimulants were Skct. II.] FRACTURES OF THE DORSAL VERTEBRiE. 437 administered. Deatli occurred on April Gtli, 1865. The necropsy revealed the course of the ball. The upper lobe of the left lung and the lower lobe of the right were found to he very much congested. There was some elfusion on the right side. The pathological specimen is No. 4082, Section I, A. M. Jil., and was contributed, with the history of tlie case, by Acting Assistant Surgeon J. P. Arthur. — Private Jacob N , Co. F, 1st Maryland Volunteers, aged 26 j'ears, was wounded at Hatcher’s Run, Virginia, February 0th, 1835, by a conoidal ball, which entered the right side of the thorax, just beneath the spine of the scapula, and lodged. He was at once taken to the hospital of the 2d division. Fifth Corps, where simple dressings were applied to the wound. On the 11th, he was transferred to the National Hospital, Baltimore. An exploration of the wound by probing only revealed an opening through the scapula, below which, examination was deemed injudicious on account of the j^roximity of the lung posteriorly. A few days after admission, tumefaction Ix'gan near the spinal column in the cellular tissue covering it. This tumefaction increased until huctuation became manifest. An incision of an inch in length was made at the point where the w^all was thinnest, and about twelve fluid ounces of pus discharged. This discharge conti nued and was very profuse for about five days, w’hen htemorrhages supervened from the posterior opening. These occurred daily, and the patient gradually sank fi'om exhaustion, and died on March 1st, 1865. At the autopsy, eight hours after death, the ball was found to have entered the scapula near the origin of the siiinous ])rocess, passed forward, inward, and to the left, at an angle of 60°, struck between the angles of the fifth and sixth ribs, bearing more In-avily upon the fifth ; was reflected upward, forwai'd, and to the left, break- ing the spinous process of the fifth dorsal vertebra, and lodging under the rhomboid muscle, beneath the deep fascia of tlie left side. A large piece of blue cloth, carried into the wound, lodged on the right side of the spinous process. A sac, filled with black matter, in great part clotted blood, averaging in breadth, from two inches in the cervical region to three inches in the scapular and four inches in the doreal and fourteen inches in length, extending from the fifth cervical to the first lumbar vertebra, was observed. On the left side, confined by the deep fascia, was an abscess, extending from the last cervical vertebra to the sixth doi-sal, about one inch in length. Having cut through the lamina of the spinal cord, the spinous processes were removed. The large veins, near the lamina that was broken by the ball, were found. The torn extremities of a vein were found, white and old looking, near the point of injury. The spinal cord ^vas thouglit to be somewhat thickened, and of an abnormal dark color. The p.athological specimen is numbered 1080, Section I, A. M. M., and was contributed, with a history of the case, by AV. G. Smull, Acting Assistant Surgeon. Case. — Private Henry F. W , Co. II, 0th Michig -n I, A. M M Museum, with the above account, by Acting Assistant burgeon b. K. bkillern. Sect. II.] FRACTURES OF THE LUMBAR VERTEBRAS. 445 Case. — Private ^Yilliam B , Co. B, 5.'ith ^Massaclinsetts, was shot while attempting to assault the provost guard, at Folly Island, South Carolina, November 11th, 18G4, at four and a half o'cloc’k r. M. ; a conoidal ball entered the left side of the abdomen, midway between the crest of the ilium and twelfth costal cartilage, and lodged. The missile was fired at a distance of nine yards. There was instant and great pain in belly and small of back, with excessive shock. Consciousness unimpaired. Little external hsemorrhage. Copious vomiting of all the contents of the stomach, unmixed with blood, within one hour. Three grains of opium were given, with some relief from pain, but no sleep was induced. The extremities were very cold and could not be warmed. He died fi’om collapse, .six hours after the reception of the injury. Necropsy: Small intestine severed at two points, allowing the escape of contents. Descending colon bruised, but not niptured, near external wound. There was about three iiints of blood in the cavity of the abdomen, but no very large vessel wounded. The body of the second lumbar vertebra was perforated transveisely, laj’ing bare, but not injuring, the cauda equina. The ball was found, its base partially flattened, near a dejmessed fracture of the inner table of the ilium, near its crest. The pathological specimen is No. 3458, Section I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon Burt G. Wilder, 55th Massachusetts Volunteers. Case. — Private John McD , Co. K, 7th Michigan Cavalry, while in a state of intoxication, on July 1st, 1863, was wounded by a ball from a Colt’s revolver (navy size), fired by the guai’d at the camp of the 1st Rhode Island Cavalry. The pistol W’as discharged at a distance of ten feet, the missile entering the left side, four inches below and a little to the light of the nipple. He dropped instantly, and upon attempting to remove him to a tent, it was discovered that he was wholly unable to move the lower limbs, and that below' the anterior superior spinous processes of the ilium there was no sensation whatever, except a very slight sense of feeling when hard pressure was made ujion the genitals. The shock and jirostration were very great, and followed the injury immediately, while the system did not respond to the stimulants exhibited. It w'as found impossible to probe the wound to any extent, and one hour after the infliction of the injury, the patient was removed to Columbian Hospital, Washington. Up to this time no blood had issued from the mouth, nor was there any emjihysema. Half an hour, after ad- mission, the patient commenced to vomit blood very freely. Although thirst was intense, he ejected the drinks given him almost as soon as swallowed. The vomiting of blood continued until four o’clock P. M., tive hours after the injury, when it ceased altogether, although water was thrown up as before. The vomiting was spasmodic, and unaccompanied by ))ain. About this time some reaction took place, and the patient W'as comparatively comfortable until a quarter before eight o’clock I>. JI., wlu'u lie became slighfly convulsed, and expired in a few minutes. There were several respirations observed after the action of the heart had ceased entirely. He was perfectly conscious to the last moment. Necropsy : Ball passed inward and downward, going between the seventh and eighth ribs, through the diaphragm near its attachment upon the left side, thence through a fold of a dependent portion of the great curvature of the stomach, through the mesentery, and entirely through the body of the second lumbar vertebra, lodging in the deep muscles of the back. The spinal cord was divided. Both the thoracic and abdominal cavities were filled with bloody serum, while at the bottom of each were coagula of considerable size. With the exception of a few old pleuritic adhesions, the body was ^perfectly healthy. The pathological sjiecimen is No. 1331, Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Surgeon A. H. Crosby. Case. — P rivate Theodore B. H , Co. F, 7th Maryland Volunteers, received a penetrating gunshot wound of the chest and abdomen at Petersburg, Virginia, June 19th, 1864. He was taken to the field hospital of the Fifth Corps, where simple dressings were applied. On Jvdy 4th, he was transferred to the 3d division hospital, Alexandria. The ball had pene- trated the lower lobe of the left lung, the symptoms being great ju-ostration, difficulty of breathing, anxiety of countenance, slight haemorrhage, and bloody expectoration. The patient was placed on his wounded side to favor discharge of blood and ])us. No foreign matter was discovered. 'The haemorrhage was controlled by rest and antiphlogistic treatment. Stimulants were carefully given. July Cth ; Hectic fever set in. Opiates, tonfes, stimulants, and beef essence. He sank rapidly, and died on July 9th, 1834. Necropsy: Ball entered between the ninth and tenth ribs, separated the former from its cartilage, passed through the lower lobe of the left lung, entered the abdomen, passed through the intestines without injury, and lodged in tlie second lumbar vertebra. The pathological specimen is No. 3349, Section I, A. M. M., and was contributed, with a history of the case, by Surgeon Edwin Bentley, U. S. V. Ca.se. — Corporal ,1. L. W , Co. A, 2d Connecticut Heavy Artillery, aged 38 years, received a gunshot jienetrating wound of the abdomen at Cedar Creek, Virginia, October I9th, 1864. He was treated in the field until October 25th, when he was sent to Patterson Park Hospital, Baltimore. The missile had entered about the ninth rib, on the left side, and i)assed out about the rib, on the right side. When admitted, the patient was sufi'ering from constitutional debility, but did not exhibit much distress otherwise. Simjde dressings were applied to the W'ound and an anodyne administered. Death resulted on October 28th, 1864. Necropsy : The ball fractured the ninth rib on the left side, passed down through the diaphragm, per- forated the spleen, then took a transverse direction through the body of the vertebrae, thence through the right lobe of the liver and out between the seventh and eighth ribs. The left side of the thorax was filled with blood and the left lung conqdetely collapsed. The immediate cause of death was internal haemorrhage from the splenic circulation and the wounds of the inter- costal arteries, induced by mechanical violence. The pathological specimen, showing two lumbar vertebra;, the lower of which is deeply grooved on its anterior face, is No. 3471, Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Surgeon A. Walsh Emory. Of musket-ball fractures of the third lumbar, the Museum possesses eight specimens. The memoranda communicated with them are appended, with wood-cuts of two of the specimens: Case. — Private Thomas D , Co. F, 1st Michigan Sharp-^tooters, aged 19 years, received a gunshot wouml of the lumbar region, at Petersburg, .Tune 24th, 1864. He was admitted, on the same day, to the field hospital of the 3d division. Ninth Coqts, and, on July 1st, sent to Stanton Hospital, Washington. Stimulants were freely administered, with subcutaneous 446 WOUNDS AND INJURIES OF THE SPINE. [CnAP. IV, injections of sulphate of morphia. Tetanus, in tlie form of opisthotonos and trismus, appeared on .he 4th. Death resulted on July 5th, 1864. At the necrop.sy, a conoidal ball was found to have entered on the left side, over the posterior part of the crest of the ilium, passed upward and inward, and lodged in the left side of the body of the third lumbar vertebra. The anterior crural nerve was injured, as was also the lower end of the left kidney. There was limited peritonitis, and a small collection of pus, say a drachm, about where the hall impinged against the peritoneum, at lower end of kidney. The intestines were not injured. The pathological specimen is No. 2702, Section I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon George A. Mursick, U. S. V. The adjoining cut represents the lumbar vertebrae, with the third fractured by a conoidal hall, which is attached. The missile appears to have passed from the left directly through the intervertebral notch between the third and fouith vertebrae, chipping the superior ai-ticular pro- cess of the fifth and the adjacent portion of the spinous process of the fourth, fractuj-ing the left transverse process of the fourth, aud emerging through the body of that vertebra on the right side. Life continued long enough for incipient caries to present itself. The specimen was contributed to the Army Medical Museum by Surgeon John A. Lidell, U. S. V., without an history. A comparison of the specimen with the registers and case-hooks of Carver Hospital, and with Dr. Lidell’s excellent paper On Injuries of the Spine (Amer. Jour, of Med. Sci., October, 1864, Vol. XLVIII), does not permit a reference of this specimen to any of the histories recorded there. It corresponds closely to several of the recorded cases, and more than one history has been attached to it; but some vital discrepancy between the history and specimen has been subse- (piently detected. The history of the case that compares most closely with the specimen Fig. l£e.— i.imibar vertebra', the represents the patient as alive a fortnight after the preparation was on the shelves of the Museum ; third fractured hj’ a imisket hall, and, in other abstracts, where dates agree, there is discordance as to position and extent of which is attached. .Spec. 2533, Sect. , ,,,, . • i c o. * u •* i t iq.i ioo.. 1, A. M. M. lesions. Ihe specimen was received from Istanton Hospital, June 18th, 1864. Case. — Private John J , Co. K, 14th Connecticut Volunteers, was wounded at Antietam, September 17ih, 1862, a ball entering the right side three inches above the crest of the ilium. He lay upon the field until the. 20th, when he was sent to Hospital No. 1, Frederick. When admitted, he could walk, but paralysis soon supervened. Retention of urine lasted for two days, after which there was no difficulty. There was no derangement of the alimentary canal. The pulse was small and weak ; the fiice flushed, and the patient sufiered greatly from bed-sores. On October 6th, he suffered great pain in the legs, which were without feeling, but warm. On the 10th, profuse sweats occuiTcd ; he sank rapidly, and died on October 11th, 1862. At the necropsy, a conoidal ball was found to have passed through the spine and spinal cord at the third lumb.ir vertebra, and lodged at the intervertebral notch on the left side. A specimen, consisting of the second, third, and fourth lumbar vertebras, having a battered ball attached, is No. 757, Section I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon G. L. I’orter, U. S. A. Case. — Private T. J. It , Co. K, 7th South Carolina Regiment, received a gunshot wound of the lumbar region, about tln-ee inches to the right of the spinal column, at Antietam, Maryland, September 17th, 1862. He was treated in the field until the 27th, when ho was sent to Hospital No. 1, Frederick. Patient became much exhausted, and died from colliquative fever on December 7th, 1832. The entrance made by the bullet had taken on a gangrenous character some days previous to death. At the necrop.sy, on opening the walls of the abdomen and removing the intestines, a blackened and sloughing condition of the parts was observable in front of the spinal column, corresponding to the second lumbar vertebra, and, on the left side, an abscess existed in which the ball was found. The abscess was iininediately in contact with the left kidney, but the latter was quite uiiatiected. Dissecting back the abdominal vessels and structures adherent to the vertebral column, an opening was found passing through the body of the third lumbar vertebra anterior to the transverse process, behind the aorta and in front of the cord, and communicating with the external opening and the sack on the left side of the column in which the ball was found. The spinal cord being uninjiired explained the absence of all paralysis during life. The pathological specimen is No. 742, Section I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon James Phillips, U. S. A. Case. — Bugler William B , Co. I, 1st United States Cavalry, received a gunshot penetrating wound of the abdomen, near Brandy Station, Virginia, August 1st, 1863. He was admitted, on the same day, to the hospital of the Cavalry Corps, Army of the Potomac, and, on the next day, was sent to Washington. He elied in an ambulance, while being ponveyed to Douglas Hospital. At the necropsy, a small bullet, as though from a carbine, was found to have entered on the right side, fractured the u]i])er edge of the eleventh rib, a little internal to the axillary line, perforated the liver on the anterior and inferior surface of the right lobe, laterally, cut through the spleen, tore away its low’er portion, cut into the left kidney, into which it impacted particles of bone, perforated the right kidney through the superior anterior edge, fractured the third lumbar vertebra, and emerged between the tenth and eleventh ribs on the left side, external to the axillary line. The omentum major protruded six inches in length from the wound of exit. The right thoracic cavity was filled with blood. The apparent cause of death was haemorrhage from the liver. The pathological specimen of the fractured vertebra is No. 1647, Section I, A. M. M. The speci- mens of the liver and fractured rib are numbered 1646 and 3291, respectively. They were contributed, with a history of the case, by Assistant Surgeon William Thomson, U. S. A. Case. — Sergeant Sylvester R , Co. B, 14th Indiana Volunteei's, was wounded at Antietam, Maryland, September 17th, 1862, by a conoidal ball, which entered the left lumbar region, half-way from the twelfth rib to the crest of the ilium, and lodged. He was taken to the field hospital of the 3d division, Second Corps, where he remained until the 29th, when he was sent to Hospital No. 1, Frederick. On October 14th, the hall was e.xtracted by Acting Assistant Surgeon Redfern Davies. Cold-water dressings were applied. Obstinate diarrhoea. No faeces passed from the wound. Paralysis of the sphincters of the Sect. II.] FRACTURES OF THE LUMBAR VERTEBRAE. 447 bladder occurred about October 20tb, and continued until the 23d, when death occurred. Necropsy : The ball did not penetrate either the abdominal or peritoneal cavities. It fractured the left transverse process and pedicle of the third lumbar. The pathological specimen is No. 80C, Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Surgeon W. W. Keen, jr. Case.— Private Elias H , Co. E, 149th Pennsylvania Volunteers, aged 40 years, was wounded on May 6th, 1864, and, on the 18th, was admitted to Douglas Hospital, Wash- ington, in a paraplegic condition, and died a few hours after. A conoidal musket ball had entered over the lower ribs of the left side, and, passing deeply in the muscles of the abdomen, lodged between the arches of the second and third lumbar vertebra and partially in the spinal canal, injuring the cord. The bladder was distended. The pathological specimen was contributed to the Army Medical Museum by Assistant Surgeon W. Thomson, U. S. A. It is represented in the adjoining wood-cut (Fig. 199.) Qase. — S ergeant W. W. C , Co. II, 26th Massachusetts Volunteers, was wounded at Opequan Creek, near Winchester, Virginia, September 19th, 1864, by a conoidal ball, which penetrated the lumbar region through the erector spinae muscle, right side, a few iucties above the posterior crest of the ilium, and lodged. The left ankle and lower third of the left femur were shattered at the same time. On the next day. Surgeon James G. Bradt, 2Gth JIassachusetts Volunteers, administered an ana?sthetic and amputated the left thigh at its upper third by antero-postorior flap operation. The patient reacted promptly and did tolerably well, but remained very weak. Stimulants and nutritious diet were administered. On September 26th, he was sent to Sheridan Depot field hospital, Winchester. By October 31st, he had gradually become anajmic, but suffered no pain. There was partial paralysis of the right leg ; no relaxation of the sphincters ; appetite moderate ; mental manifesta- tions all intact; stump healing and in good condition. Death resulted on November 3d, 1834, from asthenia and amemia, the ultimate occurrence of central nervous depression. The necropsy revealed adhesions of both lungs. The heart, liver, spleen, kidneys, and intestines were sound and normal. The ball was found lodged in the intervertebral articulation of the third and fourth lumbar vertebra. Very little pus was found in the track of the ball. The pathological specimen is No. 3796, Section I, A. M. M., and was contributed, with a history of the case, hy Acting Assistant Surgeon W. Leon Hammond. Abstracts of histories of gunshot injuries of the fourth lumbar vertebra, of cases in which the pathological specimens are preserved, are introduced here : Case. — Sergeant Adam Heim, Co. G, 105th Pennsylvania Volunteers, was wounded at Malvern Hill, Virginia, July 2d, 1862, the missile entering the right lumbar region, two inches from the spinal column, fracturing the body of the fourth lumbar vertebra, and lodging close to the spinal canal. He was treated in the field until July 7th, when he was admitted to Carver Hospital, Washington. Fmees and gas passed freely from the wound. Oj)ium, quinine, and stimulants were given. He did well, the wound in the bowels closing, and his passages were natural until an oflicious friend gave him fruit surreptitiously, when diarrhoea supervened, and the wound reopened. He died on August 3, 1862. The pathological specimen is numbered 148, Section I, A. iM. M., and was contributed by Acting Assistant Surgeon W. W. Keen, jr. Case. — C orporal L. P , Co. F, 14th New Jersey Volunteers, aged 26 years, received a gunshot wound of the back at Monocacy Junction, Maryland, July 9th, 1864. He was admitted, on the next day, to the hospital at Frederick. Three days after admission, incomplete paraplegia set in. Ho suffered, at times, with excruci.ating pains at seat of \vomul and in the lower extremities. Anodynes were freely given. Patient had no control over the sphincter ani muscle. He was, at times, delirious. Pulse slightly accelerated. Death resulted on July 18th, 1834. At the necropsy, a conoidal ball was found to have entered at a point midway between the anterior superior and the posterior superior spinous ju-oecsses of the ilium, one inch below the crest, passed inward and backward, chipped the sacrum at its posterior superior angle, fractured the fourth lumbar vertebra, and lodged in the canal. The pathological specimen is No. 3810, Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Surgeon J. C. Shinier. Case. — Private John D , Co. I, 28th Pennsylvania Volunteers, was wounded at Gettysburg, July 1st, 1833, by a conoidal ball, which entered the right side one inch above the crest of the ilium, passed inward and lodged. He was taken to the Seminary Hospital, Gettysburg, and, on the 12th, transferred to Broad and Cherry Streets Hospital, Philadelidda. When admitted, the wound looked well. The wound was probed for the ball, but without success. The bone was found bare, and a fracture of the vertebral was diagnosed. The general condition of the patient was very fair; pulse, 88; tongue slightly furred, and bowels constipated. Neither paralysis of sensation or motion was perceptible, but he complained of severe pain in the wound. Nourishing diet was ordered, with an anodyne at night, and fhe wound was dres.sed with linseed poultices. Under this treatment, he appeared to improve until the 20th, when, without any perceptible cause, his pulse rose to 112; the wound became more painful. He was seized with a nervous trembling and very free diaphoresis, and began to siidc rapidly. Milk jnmeh was ordered, and counter-irritation made over the lower part of the sjiine, but without relief. The next day the symjitoms had increased, and he was ordered a mixture of camjdior and chloroform every four hours. He continued to sink, and died on July 24th, 1633. An autopsy was made eight hours after death, when it was found that the ball had entered the signal coliinm on the right side, at the articulation of the fourth and fifth lumbar vertebra}, just in front of their transver.se jirocesses, destroyed the continuity of the spinal canal, passed obliquely upward through the body of the fourth, and lodged in that of the third lumbar vertebra, on the left side. The pathological specimen is No. 2706, Section I, A. JI. M., and consists of the first thi'ce and a section of the fourth lumbar vertebra. Caries marks the track of the missile. The cord was impinged upon by a disi)Iac(!d fragment of the fourth vei-tebra. It was contril)uted, with a history of the case, by Acting Assistant Surgeon William V. Keating. Fig. 199. — Tliird and fourtli Imnbar vertebrie, with a ball lodged between their arches and projecting into the canal. S^iec. 3523, Sect. I, A. M. M. 448 WOUNDS AND INJURIES OF THE SPINE. [Chap. IV, Case. — Private T K , alias .1 B , Troop A, Ctli United States Cavalry, aged 28 years, niai ried, was admitted to hospital at Austin, Texas, April 18th, 186G, from Belton, Texas, sixty miles distant, with gunshot wound of the posterior pelvis, received on Maich 26th; wound closed. He had been attended by a citizen phj’sician, who made no ellicient examination of the injiuy. Patient states that he received, while in the act of running, an accidental pistol shot (conical bullet, calibre .36 inch), instantaneously falling to the ground; the muscles of the lower extremities jiaralyzed ; complete loss of sensation over entire posterior pelvis ; that he was desirous of having the bullet searched for, as he should feel no jiain from any incision. Otherwise learned that on the second day after tin; receipt of his injury, lie complained much of pain across the sacral region and in the thighs; that he had lost almost entire control of his limbs from the haunches downward; could not change the position of the lower part of his body, and all attempts to move him by others gave great pain, especially across the lower ])ortion of the back. His bowels were torpid; micturition continued under his control, but he lacked the expulsive power to readily accom]ilish it. After a few days, he was able to be jflaced up in bed with a chair and pillow at his back, and to move slightly the left thigh and leg ; appetite increased; was quite cheerful, and thought to be recovering: could never rest the weight of tlie body upon the legs; shortly previous to removal to hospital, would slowly drag the legs after him when supported erect. Symj)toms on admission : Much exhausted, having made the entire journey in an army wagon ; looks emaciated and anxious ; comj)hiins especially of pain in i-ight sacrum, and of severe pain in the posterior muscles of the legs, aggravated by pressure. He cannot stand without sujiport, and makes no attempt to walk. He slowly performs the act of flexion and extension of the legs, but cannot sejiarate them when lying upon his side; superior extremities unaffected; eating but little; considerable thirst; bowels in an almost complete state of torpor ; urine passed frequently and with much difficulty. He was ordered an opiate for the evening. I’rogress of the case : On the day succeeding admission, April 19th, he was ordered a mild diuretic in mucilage of flaxseed ; dry cup.s to right saci-um, and a mild injection for the evacuation of the bowels. The application of the cups gave increased motor ])ower from the hips downward, and on the second day, the patient was able to separate the knees when lying upon his side. Becoming rested from the fatigue of his journey, he thought himself to have decidedly improved; became more cheeiful ; was able to sit upon the side of the bed when placed up ; but could only change his position by the management of the hands, and continued very weak. April 25th : Heavy beer, one quart administered ; quantity divided during the day ; urine ])assed with less difficulty, yet voided frequently. Having no increased tendency to motion of the bowels, he was, April 25th, also ordered a daily injection of cool watei-, and the use of strychnia in small doses, combined with tonics ; occasional cathartics required to relieve the torpor of tlie bowels, which resjionded more readily to croton oil than to other medicines of this class. May 5th ; Wine, tablespotjnful every three hours ; beer discontinued. To this was early added the use of eggs. Beef essence was also given freely ; little desire, however, for food. May 16th : W^hisky, made rich with milk and eggs, substituted for the wine ; dry cups continued. Under the use of stiychnia, substituted by the nux vomica, the bowels moved spon- taneously, and power obtained to promjrfly elevate the legs while lying on his back in bed, but made no attempt to walk. The medicine, however, readily exhibited its undue stimulating action, characterized by the patient as of diminished sensation from the haunches downward, with severe pain in the posterior muscles of the legs, and was discontinued; ap])etite has decreased, gradually becoming weaker. During the second and earlier part of the third week in M.ay his general tone-greatly diminished : the loss of sensation below the knees becoming almost entire, retaining, however, limited motor power. The jjower of exjjelling the urine was nearly- lost ; pa.ssed in drops, with continued painful desire to micturate ; temporarily relieved by the use of the catheter (unable to retain catheter longer than a few minutes), lu this symptom, the administration of belladonna in doses of one- fourth of a grain would, for quite a period, give the most decided relief. The j)atient lay chiefly upon his back, with the knees drawn up ; pain in legs and sacial region increased ; faeces passed involuntarily ; wet cups applied near the lower spine, once a day during four days, removing, at either time, for reason of his weakness, but a small amount of blood; no benefit whatever accruing, was discontinued ; lungs in good condition. May 24th, rejecting all food; May 25th, active delirium ; May 27 th, had continued the use of the catheter twice daily; life only prolonged bj^ the persevering use of stimulants; pulse, 120; respiration, 40, breathing almost exclusively with the diaphragm ; continued delirium ; no sensation in legs, except under hard pressure ; continued to keep tin m flexed ujion the thigh.s, and the thighs upon the pelvis; complained of intense pain in the back of pelvis and thorax, extending along the sj)ine upward,, making it difficult to rest the neck u])on the pillow; described the pain as of lying upon hot embers; continued to cry out in pain until a few minutes before expiring, which took place on the morning of the following day. May 28th. Autopsy, twenty-one hours after death; assisted by Acting Assistant Surgeon R. M. Kirk. Cicatrix near ]>osterior superior angle of the right ilium, some two inches from spine ; track of wound passing rapidly toward the spinal column, fracturing slightly the superior border of the ilium, glancing upward ovei' transverse process of the fifth lumbai' vertebra, imlx-dding small particles of the Vuillet in its transit, and finally deflecting against the lower border the spinous process of the third hmdwr vertebra, penetrated the sj)inal foramen through the posterior arch of the fourth lumbar, separating the u])per portion of the arch, and readily making its way by the elastic action of the ligamenta subflava, to which the upper border of the arch remained attached. Entering the foramen, the bullet again deflected, turning its point downward and resting within the fourth lumbar vertebra. In this position the bullet is not entire, a considerable portion being detached and lying within the upper section of the vertebra. Particles of lead were also found in the cavity of the .sections. The bullet rested within the leash of nerves forming the cauda equina near the lower left angle of foramen, its jioint quite {)enetraling to the lower border of the vertebra ; and, in passing to its jiosition, had fractured the right inferior articulating process. The nerve tissue within was injured; vertebra reduced nearly to pultaceous consistence; the softening white; membranes surrounding the point of the bullet, lacerated, injected, and of a light venous ctdor. The fourth and part of the third lumbar vertebra, with the ball attached, was contributed to the Army Medical Museum, with the above history by Assistant Surgeon C. Bacon, jr., U. S. A. The specimen is figured in the adjoining cut. Fio. 200.— Fdurtli lumbar vertebra, with fragments (if a ball impacted. Spec. 683, Sec. 1, A. M. M. Skc't. II.] FR.\('TUHES OF TIIK LUMBAR VERTEBRAE. 449 Of gunshot fractures of the fifth lumbar, two cases may he recorded, in wliicli the specimens have been preserved : Cask. — Privatu James D , Co. B, Htli Minnesota Volunteers, aged 21 years, received a gunsliot penetrating wound of the abdomen at Nashville, Tennessee, December Ifth, 18G4; he also received a gunshot fracture of the hones of the face. He was admitted, on the same ilay, to Hospital No. 8, Nashville. Whem admitted, a large ])iece of the omentmn, four inches in breadth by five inches in lengtli, protriuled from the abdominal woi nd. The're was great depression and constant vomiting. The hernia of the omentum was reduced. He died on Dccend)er 18th, 1864. At the necropsy, a conoidal ball was found to have entered three inches posterior to the anterior superior spinous process, one inch above the crest of the ilium, passed inward, penetrated ,the ileum at two points, slightly fractured the body of the last lumber vertebra, and lodged in the right iliac fossa. There was intense peritonitis everywhere prev.alent, the membrane being injected and of a red and green color, and, at many points over the viscera, layers of lymph were found. Facal matter, mixed with esca})ed blood, was found about the signal column and in pelvic cavity. The right ilium was ronghened and denuded. The pathological specimen is No. 3750, Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Suigeon H. C. May. Ca.se. — Private Michael H , Co. D, 13th New York Volunteers, received a gunshot penetrating wound of the lumbar region at Gaines's Mill, Virginia, June 27th, 1862. He was taken, prisoner and conveyed to Richmond, where he remained until July 27th, when he was paroled and sent to the hospital at Chester, Pennsylvania. About Sejitember 5th, ho was sent, with others, to Fort Delaware, for insubordination, and thence was transferred to Sixteenth and Filbert Streets Hospital, on September 18th. From the first, he suffered no unusual incouvenience; the wound healed slowlj' but entirely, and the general symptoms were not sufficient to attract attention. On October 20th, after dissipation, he comjJained of pain in the left knee, at times very intense, depriving him of rest. The wound reopened and discharged freely ; a slough formed over the lower part of the sacrum three or four inches in diameter, and so deep as to lay the bone bare. A lumbar and psoas abscess develo]>ed itself; the pain in the left knee increased greatly, and the leg became swollen and tender to pressure. The abscess in the loin was opened by a valvular incision, and three pints of pus evacuated with great relief to the pain in the leg and general improvement in the condition of the patient. The wound of entrance of the ball was very small, only admitting readil}' an ej'ed probe. About December 20th, both legs load become swollen, the left one red with local inflammation at its upper third. There was not, at any time, paralysis of motion or sensation of the lower extremities. There was no diarriioea, and the stomach generally retained the anodynes, stimulants, and nouri.shing diet with which he was liberally supplied. He died of exhaustion on December 27th, 1862. The necropsy revealed an extensive abscess, reaching from the left kidney to Poupart's ligament. In the pelvis, in contact with the sacrum, was another abscess, while the tissues of the pelvis, at its back part, were buried in effusions of jdastic matter. The ball was found lodged in the spinal canal, opposite the fifth lund)ar vertebra. It had entered on the right side of the spinal ridge of the sacrum, about its middle, passed diagonally upward, and spent its force against the left wall of the canal of th.e first sacral and fifth lumbar vertebra?. The left lamina of the first sacral bone was carried awmy. The ball passed up the canal outside the theca of the spinal cord. The bodies of the fourth and fifth lumbar vertebrae were carious, and the inter- vertebral cartilage between them entirely destroyed, leaving a gaping space of the left side of tin; first and second sacral bones, which were necrosed and discolored, as was also the fifth throughout its thickness, and the cornea on its back parts. The first and second left sacral nerves seemed most involved by the diseased bones, but the lumbar j)lexus of the left side w’as entangled in its course in the diseased mass occupying the basin of the pelvis. The most remarkable feature of the case was that the ball should enter and occupy the spinal canal, pressing upon the spinal cord through its mend)ranes without affecting the movement or sensation of the lower limbs. The complete closure of the woimd, and the development of the disease in the bony Structures that had received the shock of the hall, three months after the injury, w'as also wortliy of remark. The pathological specimen is No. 1198, Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Surg(!on George R. Moorehouse. A very complicated case, in wliicli the lumbar vertebrae were imjdicated, lint the thoracic and abdominal viscera as well, will be reverted to under the head of thoracentesis : ♦ Case. — Corporal Samuel Foulkrod, Co. G, 56th Pennsylvania Volunteer,s, aged 34 years, was wounded at the Wilder- ness, Virginia, May 6th, 1864, by a conoidal ball, which entered the back in the lumbar region, and lodged. He was treated in the field, aiid^ on May 12th, sent to the 3d division hospital, Alexandria. It was thought that some of the vertebral processes were slmttered. Several fragments of bone came away, and the wound lu'aled very slowly. After the wound healed, abscesses formed in the sacral region from time to time, which gave vent to considerable jmrulent collections. He was transferred, on October 8th, 1864, to the 102d companv', 2d battalion. Veteran Reserve Corps. On February 11th, 1865, the ])atient had an attack of acute plemisy. Wet cups wore apjilied to the right chest, and six or eight ounces of blood withdrawn. This was followed by fomentations and jnirgativcs, with an anodyne at night. February 12th: Abatement of febrile action. Effusion in right pleural sac, extending up to the fifth rib anteriorly. Patient jdaced in an ui)right j)osition. February 20th, accumulation in right pleural sac has increased. Flatness, on percussion, as high as the third rib anteriorly; no res])iratory act audible below this point. No dy.spncca. Decubitus on right side. Appetite fair; pulse 90, and soft. Patient com])lained of weakness. Februaiy 28th, marked increase of fluid in chest. On March 2d. a rapid accumulation was noticeable; complete flatness on right side, extending under. Liver de])re.ssed three or four inches. Apex of heart, two inches to the left of the nipi)le. Great dyspnoea; jndse, 130. Hectic fever, fdlowed by ])rofuse perspiration. The operation of thoracentesis was decided upon, and was performed by Assistant Surgeon Samuel 15. Ward, U. S. V. A straight trochar was ))assed into the pleural sac between the fifth and sixth ribs, in the lateral region of the thorax, and fourteen and a half pints of healthy pus withdrawn. The ))atient experienced no faintness during the operation and felt greatly relieved. After the operation, the heart and liver returned to 450 WOUNDS AND INJURIES OF THE SPINE. [Chap. IV, tlieir positions. The condition of pneuino-liydro-thorax appeared, giving rise to the metallic tinkling and amphoric voice. Stimulants, anodynes, and nutritious diet, with absorbents, expectorants, and counter-irritants constituted the main treatment. During the month of March, the accumulation returned to a great extent, the dulness extending as high as the fourth rib. On April 1st, the incision of operation burst open, giving vent to over a pint of blood, and afterward continued discharging. Several abscesses were opened on the right thigh and leg. On April 15th, erysipelas appeared on the face, terminating favorably in a few days. On the 25th, he was transferred to the Sickel branch hospital, at which time he was gaining strength, and his case was very hopeful. Phthisis pulmonalis supervened, and death resulted on June ICth, 1865. The case is reported by Surgeon Edwin Bentley u. s. y. Before summing up tlie results of the entire series of cases of injuries of the spine, wood- cut illustrations may he introduced, that were not available when the abstracts to which they belonged were printed ; and also a few more abstracts of the more remarkable and compli- cated injuries of the vertebral column. Fig. 201 represents the appearance of the lower por- tion of the spinal cord in the first case described on page 426, that of a soldier whose spine was fractured by the falling of a tree across his loins. The tubular nerve filaments have been curiously dissected out by the pus in which the cord was bathed, and form a leash. The frac- tured vertebra is represented in Fig. 202. The body is broken across nearly transversely; the spinous and left transverse process impinged upon the medulla. Fig. 203 has reference to the case of Sei'geant C , 26th Massachusetts, detailed on page 447. The ball, penetrating the thick lumbar muscles, shattered the right upper E'M Fig. 201. — Lower part of spinal cord lacerated at the dorso-lumharjunctH n. Spec. 150, Sect. I, A. M. M. Fig. 202 Transverse simple fracture of first lumbar vertebra. Spec. 149, Sect. I, A. M. M. Fig. 203. — Third and fourth lumbar vertebra?, with a conoidal ball imbedded in the inter-vertebral disk. Spec. 379tj, Sect. I, A. M. M. oblique process, and buried itself so deeply in the intervertebral space as to encroach but little on the canal; the patient survived the injury six weeks. To the five examples of partial recovery from gunshot fractures of the cervical vertebrae recorded on page 405, at the beginning of this Section, may be added the following: Case. — Private Daniel Eicli, Co. B, 55th Pennsylvania Volunteers, aged 21 years, having been wounded at the battle of Pocotaligo, October 22d, 1862, was admitted to Hospital No. 1, Beaufort, South Carolina, on the 24th. A ball had entered the sternum near the clavicular articulation of the left side and lodged in the spinal column. The patient spat blood in small quantities at the moment of the injury, but walked to the place of embarkation, a distance of five or six miles. He was obliged to lie on his back, and had lost power in both arms, to some extent. When admitted to hospital, his face was flushed and dusky, coarse rdles were audible in the bronchia, and the pulse was accelerated. Tartrate of antimony, in doses of one-eighth of a grain, every four hours, was prescribed, with low diet, and wet dressings to wound. I did not deem it advisable to bleed, as the patient said his wound had bled much. October 25th: Excitement of vascular system less; the medicine had sickened him, and acted on the bowels. A poultice was ordered, and medicine to be continued, with low diet. Decubitus dorsal, and arms lying by his side helpless, or rather unable to move them without pain in the shoulders; his si)ine seems perfectly rigid, and in being raised to take his food, which he does in a chair, he allows no one to touch him anywhere, except upon the head, and thus, as a stick, is lifted into the upright position. The cervical vertebra; are tender to the touch, as are also the upper dorsal vertebrae. October 2oth: Much in the same condition; antimony continued; low diet, and poultice to wound. October 27th; Respiration easy; pulse nearly natural; wound suppurating. Antimony discontinued, and ordered half diet; feeling hungry. Continued much in the same condition until October 31st, when the soft parts covering the upper portion of the sternum had become red and fluctuating. The discharge could, with some difficulty, be forced out of the wound on the left side, but did not do so without as.sistancc. I therefore made a free incision in this, and gave it vent. An opening into the chest, through the sternum, was apparent to the finger introduced through the wound; being feverish again, spirit of mindererus was ordered. A coarse rattle annoyed him very much, but subsided under that treatment. The wound discharges freely, and is doing well at this date. Sect. II.] FPw\CTUKP:S 01'’ tup: LUMBAK VKRTPIBRyp;. 451 November 4th, but the stiffness of spine and inability to move the arms remain. November 18th : The poultice was. discon- tinued yesterday, and cerate dressings ordered. The patient can now move his arms somewhat, and sits up an hour or two daily. Cough disappeared suddenly, a week since. I think it was when he first sat up, and thus allowed the matter to run out that this symptom disappeared. Discharge is now very slight and healthy. December 1st, 1862 ; Rich has been walking around the ward since the 20th of November, and complains only of a feeling of stifliiess in the spine and upper extremities. He walks as if all the parts above the pelvis were ossified together. Yesterday a small piece of bone came out of the opening over the sternum; it was evidently a portion of the sternum, and was of the size of a ten-cent piece. The three openings discharge but little, and are filled with very flabby granulations, which were penciled with nitrate of silver. A cerate cloth is kept to the wounds. December 20th: Rich has been doing very well since last report, sitting up much of the time, and occasionally walking about the room. Erysipelatous inflammation appeared to-day on the chest. December 27th: The erysipelas has successively invaded the chest, left arm, shoulder, and back, but is now disappearing. There is very little discharge from the wound. There still remains an immobility of the spine and arms, which prevents him helping himself much. December 28th : Sent to northern hospital, per steamer Star of the South. “Washington, D. C., November, 1865. — This man is now in the 1st battalion, V. R. C., to which he was transferred about a year since, and has done military duty since that time, and appears well at present.” The above details were reported by Surgeon R. B. Bontecou, U. S. V. Rich was discharged the service on November ICth, 1865, and pensioned, liis disability being rated total and permanent. Pension Examiner C. H. Rahter reports, under date of November 20th, 1868, that the patient's respiration is huiried, and he complains of constant pain in the chest. On May 3d, 1871, Pension Examiner S. M. Finley reports that “the wounds discharge freely eveiy four or five months. There is great tenderness over the second rih ; is much troubled with cough and breathes hurriedly. There is dulness on percussion, at the base of the left lung.” The following are examples of partial recovery after gunshot injuries of the dorsal or lumbar spine: Case. — Private Alfred Frederick, Co. B, 16th New Y’ork Artillery, aged 18 years, was wounded at Chapin’s Farm, Virginia, October 7th, 1864, by a musket ball, which entered at the dorsal surface of tlie left scapula, below the supra-spinous process, and emerged posterioily and a little to the right of the second dorsal vertebra, fracturing, in its course, the spinous process of the scapula and second dorsal vertebra. He was taken to the regimental hospital, and, on the next day, sent to the base hospital of the Eighteenth Corps. On October 26th, he was sent to Hampton Hospital, Fort Monroe, whence he was returned to duty on February Cth, 1865. Pension Examiner A. P. Cook, reports on August 5th, 1869, that there is inability to elevate the ann to the head, from adhesion of the muscular sheaths, incapacitating him from performing manual labor. Case. — Private Nicholas T. Hall, Co. I, 1st Massachusetts Volunteers, aged 19 years, was wounded at Fair Oaks, June 1st, 1862, by a conoidal ball, which entered near the anterior superior spinous process of the left ilium .and lodged in a lumbar vertebra. He was treated in the field until June 29th, when he was sent to Stone Hospital, Washington, whence he was discharged from service on August 26th, 1862. There was paralysis of the lower extremities. Pension Examiner George Stevens Jones reports, October 4th, 1862, “the ball has probably lodged in the vertebrae, and compressed the spin.al marrow. The man is a great sufferer, and is incurable.” Disability total. The following abstracts relate to fatal complicated gunshot injuries of clilferent parts of the vertebral column. It is unusual to find balls perforating the lamince and dividing the cord with comparatively little injury to the osseous structures. The following is an example of such an injury: Case. — Corporal W. N , Co. C, 142d Pennsylvania Volunteers, having been wounded at Fredericksburg, December 1.3th, was admitted to hospital at Alexandria, December 19th, 1862. A ball had entered one inch and a h.alf above the outer third of the right clavicle and lodged. The patient was weak, and had an anxious countenance; there was consider.able dyspnoea, with a full but weak pulse, and suppuration from the wound was profuse. On December 23d, diarrhoea set in, attended with anorexia; otherwise the condition of the p.atient remained unchanged. The diarrhoea became worse by the 28th, and dyspnoea increased, the breatli passing through the wound. The patient died on December 31st, 1832, with very great dyspnoea. At the autopsy, it was found that the ball had passed longitudinally through the inferior lobe of the right lung, impinged upon the body of one of the dorsal vertebrae, a splinter of which still adheres to the ball, and lodged under the greater curvature of stomach. There was red hepatization of the injured lung, and a little pus was found in the thorax. There was nothing to indicate the occurrence of hmmoiThage. The treatment of this case was expectant. The missile was contributed to the Army Medical Museum, with the foregoing account, hy Acting Assistant Surgeon G. F. French. It is repre- sented in the adjoining cut (Fig. 204). Case. — Private li. H. Godwin, Co. K, 31st Virginia Regiment, aged 26 years, was admitted into Chimborazo Hospital No. 1, Richmond, Virginia, with a gunshot injury of the spine, received on Juno 1st, 1864, the ball entering the lirst lumbar vertebra and ranging upward. He died June 3d, 1864. Paralysis did not occur. Surgeon P. F. Brown, 1’. A. C. S., reports the case. Case. — Private Salvador Real, Troop F, 1st New Mexico Cavalry, was .admitted to hospital at Fort Wingate, New Mexico, for a wound received in an attack by Indians near that post, on M.ay 24th, 1865. A rifle ball had entered immediately below the spine of the right 8C.apula, passed obliquely downward .and inw.ard, and entered the thorax through one of the l ight Fig. 204.— Conoidal mus- ket ballsnmewliat curved, •W’ith the apex obliquely flattened and a fragment rent ofT. Spec. 4483, Sect. 1, A. M. M. 452 WOUNDS AND INJUEIES OF THE SPINE. [Chap. IV, i-ibs two inches from the vertebral column. The cliief symptoms were inflammation of the liglit lung, higli fever, and bloody expectoration. The treatment pursued was strictly antiphlogistic; bleeding, purging, sedatives, and spare diet. Death occurred on May ‘28th, 1835. At the autopsy, the right lung was found completely hepatized; the left lung was in a healthy condition. A number of splinters of bone from the fractured rib were imbedded in the right lung adjacent the wound, and a small quantity of lymph covered the lower and back part of the lung in proximity to the wound. The ball was imbedded in the body of one of the vertebra nearly opposite the wound of entry. The case is rej)orted by Acting Assistant Surgeon Charles A. McQueston. Case. — Private John Lowe, Co. C, 31st Indiana Volunteers, aged 23 years, was wounded at Pittsburg Landing, Tennessee, April 7th, 1832, by a conoidal hall, which entered near the clavicle to the left of the sternum, and lodged near the spine on the same side. On April 11th, he was admitted to the hospital at Mound City, Illinois. Haemoptysis for first four days. Severe pain in lung and labored respiration. Arterial sedatives weie given, with an anodyne at night. On April 28th, he was transferred to Hospital No. 4, Evansville, Indiana. The ball had been extracted previous to admission. On May 2d and ICth, haemorrhage occurred from the large vessels in iqiper j)art of chest. He bled from the mouth and posterior wound in both instances, and became much reduced in strength without syncope supervening. Astringents of acetate of lead and opium were given, with mild antiphlogistics, and quiet ordered. The wounds healed. Death resulted August 14, 1862, from paralysis, referred to necrosis of the spinal colmnn. The case is reported by Surgeon E. C. Franklin, U. S. V. Case. — J. IV. B , was killed on April 26th, 1865, by a conoidal pistol ball, fired at the distance of a few yards, from a cavalry revolver. The missile perforated the base of the right lamina of the fourth cervical vertebra, fracturing it longitudinally and separating it by a fissure from the spinous process, at the same time fracturing the fifth vertebra through its pedicle, and involving that transverse process. The projectile then traversed the spinal canal almost horizontally, but with a slight inclination downward and backward, perforating the cord, which was found much torn and discolored by blood. (See Specimen 4087, Sect. I, A. M. M.) The ball then shattered the bases of the left fourth and fifth laminae, driving bony fragments among the muscles, and made its exit at the letl side of the neck, nearly opposite the point of entrance. It avoided the large cervical vessels and the filaments of the second and third cervical nerves. These facts were determined at the autopsy, which was made on Ajnil 28th. Immediately after the reception of the injury, there was very general paralysis. The phrenic nerves performed their functions; but the BlKiwitiK gunshot fracture of respiration was diaphragmatic, of course, and labored and slow. Deglutition was impracticable, 408B, Sect. I, A. M. M. and one or two attempts at articulation were unintelligible. Death, trom asphyxia, took place about two hours after the reception of injury. The next is an abstract of a case complicated by tetanic symptoms. Others have been recorded on pp. 444 and 445, ante. • Case. — Private John Ratteo, Battery C, 5th United States Artillery, aged 28 years, was wounded at Gettysburg, July 1st, 1863, by a conoidal ball, which entered below the spine of the left scapula, and lodged in the angle between the spinous and transverse processes of the eighth dorsal vertebra, fracturing, but not di.splacing the .spinous process. After being wounded, he walked to the field hospital without assistance, and was able to move about and help himself until the 6th, when clonic spasms of the abdominal muscles and diaphragm set in, which continued steadily increasing in intensity. Anmsthetics were administered, and the urine was drawn oft' by a catheter. On the evening of the next day, he fell into a sleep, upon awakening from which the spasms returned, and continued until death, which occurred at eleven o'clock P. M., July 7th, 1863. Concluding Observations. — Gnnsliot injuries of the vertebral column are, of course, very serious. The following table shows that more than half of those cases that came under treatment were fatal; and many who suffered from such injuries must have rested on the field: Table XLX. Hesidts of Six Hundred and Forty-two Cases of Gunshot Injuries of the Vertehroe. llEGION. Cases. Died. Discharged. Duty. UukiiowD. Percentage of Mortality. Cervical 91 63 19 8 1 70.0 Dorsal niY 87 32 18 63.5 Lumbar 149 66 51 28 4 45.5 2 1 1 .50. 3 3 100. Vcrtebrm not stated 260 1‘29 72 50 9 51.4 Aggregate 642 349 175 104 14 55.5 riG. 205. — Third, fourth, and fifth cendcal vertebrtB, Sfxt. II.] EEMARKS ON GUNSHOT INJUEIES OF THE VEETEBENi. 453 Among the cases enumerated in the foregoing table, — which includes those of which abstracts have been given, — the following complications were noted : j\Iusket balls lodged in bodies or apophyses of vertebrse in such a manner that their precise position could not be ascertained, or else So impacted that all efforts for their extraction were fruitless. Several such examples are figured in the preceding pages of this Section. (See Figuees 190, 192, 193, 194, 195, 196, 197, 198, 199, 200, 203.) The total number reported, of such cases, was seventy-three :^Twelve in cervical region, with eight deaths, two complete recoveries, one discharge with slight disability, and one undetermined case ; thirty-four in the dorsal region, of which thirty-one were fatal, one recovered, one discharged, one with result unknown ; twenfiy-one of the lumbar region, with sixteen deaths and five discharges for disability ; six in which the region was not specified, with three deaths, tAvo discharges, and one recovery. In fifty-four cases of gunshot injury of the vertebrae, complicated by traumatic lesions of the cord, forty-two were fatal, and twelve partially recovered and were discharged, Avith various degrees of physical disability. The cases of contusion and commotion of the spinal cord are not included in this category. Abstracts of fourteen of the fatal cases have been printed in the foregoing pages. One of these, the second on page 439, in Avhich the patient is reported, by Surgeon E. Donnelly, 2d Pennsylvania Reserves, to have survived eight days, after a conoidal pistol ball had passed into the spinal canal through the apophyses of the eighth dorsal and upAvard “through the medulla spinalis as far as the first cervical,” is so extraordinary, that the authority, accidentally omitted, is here recorded. The fifty-four cases, Avhere injury of the cord is mentioned, cannot possibly include all in Avhich that com- plication existed. In the Army Medical Museum alone, there are fifty-tAvo specimens of gunshot injuries of the sj^ne involving the cord, nearly all procured from cases included in Table XIX. The Museum contains seventy-six specimens shoAving the results of gunshot fracture of the A-ertebrse.''' In nineteen cases primarily fatal, the cord escaped injury in four only ; in fifty-seven examples of secondary pathological conditions, the cord Avas involved in thirty-seven. Estimating the relative frequency of injury to the cord, in gunshot frac- tures of the vertebrae, by the fatal cases alone, the percentage Avould be 71.0. Paralysis is mentioned as a prominent symptom in only one hundred and fifty-one of the six hundred and forty-tAvo cases enumerated in the table. Making every alloAvance for the considerable proportion of cases in Avhich the lesions Avere confined to the apophyses, it must be regarded as probable that this complication Avas not ahvays noticed Avhen present. There Avere not a foAV instances in Avhich paralysis Avas absent eAmn Avhere the cord was injured. (See Cases of J. R , p. 444 ; J. D p. 447 ; M. II , p. 449 ; R. H. Goodwin, p. 451.) All of these Avere examples of injury of the lumbar A^ertebrco.'j* In the case of Bowers (p. 444), there Avas no paralysis, except of the bladder. The occurrence of bed- sores is noted in tAventy-tAvo of the six Imndred and forty-tAvo cases, eleven terininating fatally. In fourteen cases, of which tAvelve terminated fatally, injuries of the Amrtebrm Avere complicated by AAmunds of the lung. In fifteen cases the abdominal caAuty Avas pene- trated ; there Avas a single partial recovery. Abstracts of some of the fatal injuries of the spine, complicated by penetration of the thoracic or abdominal cavities or both, have been cited on pp. 441, 442, and 446, ante. In several ’instances the lung, diaphragm, livei’, spleen, or kidney, Avere implicated. *Scc Cat. of Surff.y Sect. A. M. M., p. 57, ct seq. t See Mr. SUAW'rt paper in lIOLMES tt System {Op. ci7., Vol. II, p. 38iD. I' >ur interesting cases of total absence of paralysis in fractures of the lower lumbar rrgi. Piontecou, IT. S. A'^.. on the same day. The harniorrhagc recurred on June 2d, when re-ligation was jierforined. Death resulted in about three hours after the second operation. The case is taken from the Harewood Hospital reports. Tliougli the surgeon fdloAved the generally accepted practice* in the folloAving case, one cannot refrain from a feeling of regret that an attempt, at least, Avas not made to place a double ligature on the internal carotid at the part Avounded. If successful, it Avould have been a glorious achieA^ement, and it could not have had a Avorse result than the Anellian operation that Avas adopted : Ca.su. — Ligation of Common Carotid for Gvnslwt TTound of the Internal Carotid. — Orderly Sergeant Vincent L. Keiflin, Co. K, lObth Pennsylvania, was wounded at Gettysburg, July 2d, 1863, by a conoidal ball, which entered the right side of the neck, just below and posterior to the ear, and lodged. He was treated in the field until July 10th, when he was sent to the hospital at A'ork. His name does not appear on the register of the Third Corps Hospital, where most of the wounded of his regiment were treated. On the 12th, a severe liaemorrhage occurred from the wound, and could not he controlled hy the ordinary means. The right common carotid artery was tied by Surgeon Henry Palmer, U. S. A^., on the 13th. The patient died on the morning of July 14th, 1863. Necropsy : The internal carotid artery was nearly severed at the point where it enters the skull. The right arch of the atlas was shattered, and its fragments pressed on the vertebral artery. Three jiieces of the hall were extracted. The case is reported by Acting Assistant Surgeon H. E. Bowen, in charge of the case hooks of Tork Hospital. The medulla appears to have escaped all injury. In the next case there is no indication of the source of bleeding ; but it Avas probably a lesion of some of the vessels in the axilla, as the operator Avould hardly have tied the left subclavian Avithin the scaleni, Avithout specifying the fact : Case. — lAgation of Left Subclavian. — A. C. Howard, Confederate, aged 19 years, received at Fair Oaks, May 31&t, 1862, a gunshot wound, the ball passing through the left shoulder, injuring the spine and causing paralysis. On June 7th, the left subclavian artery was ligated on account of haemorrhage. He died on June 18th, 1862. [The case is reported by Dr. H. L. Thomas, in the Confederate States Medical and Surgical Journal, A^ol. I, p. 186.t] The folloAving case, reported by Assistant Surgeon Robert F. Weir, U- S. A., is very instructiA^e : Ca.se. — Diffuse Traumatic Aneurism ; If’ound of the SjAnal Cord; lAgation of the Carotid; Death; Autopsy. — “In the afternoon of .Sejitember 30th, 1862, I was requested to see in consultation, by Surgeon Thurston, U. S. A'^., and Acting Assistant Surgeon C. P. Herrington, at Frederick Hospital No. 4, Private Henry Herman, 12th Pennsylvania Eeserves, aged 23 years, who was wounded at the battle of Antietam, by a buckshot, which had entered on the right side of the nock on a level with the upper portion of the thyroid cartilage and on the anterior margin of the sterno-mastoid. Of his history prior to his entrance into this hospital, September 24th, little could be ascertained, but the following was obtained from the patient. On the 2Gth instant, some haemorrhage had occurred, twelve days after the reception of the injury. The bleeding had been checked, as was thought, by ])luggiug the small opening of the wound with lint saturated with liquor ferri pcrsulphatis. A pulsating tumor then rapidly formed and extended so that at four o’clock P. M. of the same day it had reached from the maxilla to the clavicle, and from the sterno-mastoid to the median line. Although the course of the missile was unknown, there had resulted paralysis of the right leg and partial loss of the functions of the right arm. There was no indication of urinary trouhle. At the hour of consultation the tumor w.as reported to have increased much iu sine and had now crowded the trachea considerably to the left side. The covering of the false aneurism was tense, and pulsation and a harsh thrill were detected on palpation. The ])lug of lint remains in yet, held firmly by clotted blood. The mean pulse was 65 and irregular, but became quiet — jirobably from the amount of rereitum riride i\\nl had been given him, to wit: from eleven o’clock A. M. (it now being five o’clock P. Jl.), eight drops every one and a half hours. The respiration was slow and irregular, and somewhat violent and humid, with lividity of the face. Even if the cord had been injured by the shot, which was not thought probable by many of the assistants, it was decided to operate, since death was imminent from the recurrence of the severe haemorrhage, and I was requested to perform the operation. Having carefully assigned their duties to my assistants, the lint idug was removed, and immediately the wound was enlarged by me, with probe pointed instruments, sufficiently to admit my two fingers to the bottom of the cavity. I was so fortunate as to reach and compress the opening in the artery with very little difficulty, and thus effectually control the haemorrhage, which at * I think tliat it is unfortunate that the last edition of Gray's Anatomy (2d Holmes, London, 18G6, p. 35fi), a work in the hands of so many students, should recommend the ligation of the common carotid for wounds of the intemal carotid. — Compiler. t In connection with this case, Dr. H. L. THOMAS, who did much of the statistical work in the Confederate Surgeon General's Oftice, remarks: “In many of the reports the data are so meagre as not to furnish any satisfactory conclusiiuis with regard to the gravity of tlie case. Ilrevity is a very commendable feature in clinical reports, but should nut be pushed to the extent (f robbing the ease of its interest. ‘Alexander died — Alexander was buried ; ’ but tliere are some people who would be curious to know how be died and when he was buried ; and it is a lean obituary that does not give these small items.'* Sect. III.] EEMOVAL OF FRAGMENTS OF VERTEBRA. 457 first had been quite profuse, thougli of short duration. Throughout the wliole of tlie protracted operation, it was noticed witli what ease the bleeding fi’oni the artery was checked — so little pressure was recjuired. The clots were now turned out and the incision prolonged downward to the clavicle, and upward about one inch — the length of the entire incision being three and one- fourth to four inches. Owing to the obscurity of the tissues from infiltrated blood and the dis]ilacenient of the parts from ])rcssure, great difficulty was experienced in securing the artery above and below the opening, which the end of the forefinger neatly closed. It was only after long and repeated attempts that the proximal part of the carotid was exposed and a ligature placed around it b}' means of !Mott’s aneurism needle. The finger at this time became accidentally displaced from the opening, and it was noticed that the blood welled from the upper carotid for five or six seconds before jetting. The ligature of the distal portion was then applied, which entirely checked the bleeding. At the time the first ligature was apjdied, great disturbance in the respiratory movements occuri'cd, suggesting the idea that the pneumogastric nerve had been included in the ligature. After ten or fifteen minutes they became more regular. It was noticed also, but freely after six ligatures had been applied, that hemiplegia of the left side had taken place, with tendency to sleep; patient was easily aroused, and that the right arm alone was movable; deglutition, however, was not impaired. The opening in the artery was plainly visible after the ligation. It was oval in shape, and about a quarter of an inch long. Almost eight ounces of blood had been lost, being much less than anticipated from so formidable an operation, which had occupied more than two hours. Six and a half o’clock P. M. : At the tumefaction, jndse (16, and of moderate force; respiration ranging from 36 to 48. No other symptoms appeared to justify the idea of a ligation of the pneumogastric nerve. Vision of both eyes was impaired, though the left pupil did not contract upon exposure to strong light ; the condition of the pupils, jirior to the operation, had not been noticed. Seven and a half o’clock p. M. : The trachea had returned to its noiinal position. Is taking one-half ounce of brandy every fifteen minutes; pulse 95, and a little weak. Is still somnolent, and an involuntary evacuation of the bowels has taken place. October 1st, fifteen minutes past six o’clock a. m. : Quite a severe haemorrhage occurred, which, however, was easily arrested by the application of liquor fern persulphatis by the surgeon in attendance. This was thought to have originated from some vessel divided during the operation. Paralysis continued the same, indicating cerebral lesion. The patient gradually sank, becoming more profoundly immersed in stupor and although both pupils acted regulaily when exposed to light, at twenty-five minutes past two o’clock P. Si. he died. The autopsy, made twenty-four hours after, revealed the following facts : Rigor mortis tolerably well marked. The skin was black from the jaws to the second rib on the entire right side, and the whole body greatly puffed up. A careful dissection of the neck on the right side was made. Everything was found gi-eatly disarranged and displaced by reason of the false aneurism and the operation. All the veins were immensely distended with air, though no injury to their calibre was discovered. The omo-hyoid had been divided. The descendens noni nerve was not found, but the communicans noni nerve was uninjured. Neither the internal jugular vein nor the pneumogastric nerve were found to be included in the ligature, nor did the nerve seem to have been affected through its pi’oper sheath by the persulphate of iron, as was thought might have occurred. On examining the artery it was found that the ligature had been applied three-eighths of an inch above and five-eighths of an inch below the w'ound, but the upper one was somewhat loose, perhaps enough so as to account for the recurrence of the hasmorrhage after the operation, though, as it controlled the haemorrhage, at first, it seems more reasonable to suppose that the haemorrhage came from the superior thyroid, which had itself, or some of its branches, been divided in the operation. The wound was made in the sheatli on the inner side, three-eighths of an inch below the border of the superior thyroid cartilage and one-eighth of an inch below the bifurcation of the artery. It was about three-eighths of an inch long and nearly as broad, with a narrow connecting band running longitudinally. The ■walls of the artery seemed healthy, save immediately about tlie wound. The three lower cervical and two upj)er dorsal vertebrm and the cord were exposed by sawing through the lamina;. The shot had entered the spine anteriorly, and at the lower edge of the sixth cervical vertebra of the l ight side, just internal to the vertebral aatery, which was uninjured. It penetrated the cord and was found within the theca in the median line, just above the lower border of the seventh cervical vertebra, posteriorly. Just within the cord, at the point of entrance of the shot, was a spicula of bone about a quarter of an inch long. The membranes of the cord for three-eighths of an inch above and below the lodgment of the hall were foilnd inflamed. The brain was found, in the middle lohe of the right side, to be softer than that of the left. Just to tiie right of the lamina cinerea, where the middle lobe overlaps the anterior, was a spot, of about one inch in diameter, where the substance of the brain was greatly disintegrated, and in a liquid condition. It had almost formed an abscess — otherwise healthy. The specimens were preserved. Remo.val of Fragments of Vertebrae. — Of formal trepanning of tlio vertebrae no instances were reported, but a few examples of the extraction of recent spicula3 from the apophyses ; of exfoliations and necrosed portions of the bodies and processes of the vertebrae ; and even of operations for the removal of fractured fragments from the lateral and posterior portions of the apophyses, were recorded. In the preceding Section, on page 433 , abstracts are given of the cases of IMoran, Weaver, and Freeman in which fragments were removed after gunshot fractures of the dorsal vertebrae. All of these patients made excellent recoveries. The operator in the case of Freeman, Assistant Surgeon J. S. Billings, U. S. A., has since mentioned that quite lai’ge portions of bone were removed. Scanty particulars of some of the other cases included in Table XX are appended : Case. — Private Thomas Wells, Co. C, 20th New York Militia, aged 21 years, was wounded at Gettysburg on July 1st, 1863, by a round musket ball, which fractured and lodged in the lateral process of the fifth dorsal vertebra. On .July 18lh, he ■was admitted from Chester to the Haddington Hospital, Philadelphia. The wound was painful and discharges! freely, and 5. V, enemy until .Tune 16tli, when lie was paroled and sent to the University Hospital, New Orleans. Simple dressings were applied. He was transferred to Camp Parole on February 2d, 18G4, and W'as mustered out of service on October 18th, 18G5. The Pension E.xamiuing Board at Brooklyn, New York, report, December 6th, 1871 : “gunshot wound of left thorax, with injury to eighth and ninth ribs. The integuments are adherent to the ribs at the point of injury, and the muscles attached to the parts are diminished in power.” Ca.se. — Private Edward Dillingham, Co. M, 1st United States Cavalry, aged 21 years, was wounded near Boonsboro’, Maryland, July 8th, 1863, by a conoidal ball, which passed through the anterior portion of the upper third of the left arm, grazing the bone, emerged, and entered the left breast, one inch above the nipple, passed in a direct line transversely across the chest, fracturing the sternum, and lodged in the anterior fold of the right axilla. He was admitted, on the next day, to the hospital at Frederick, Maryland, breathing rapidly and with considerable difficulty. The ball was immediately extracted. On the next day dyspnoea set in, due to double pleurisy from contiguity of wound to the pleura and depression of the sternum. Stimul.ants and anodynes were administered, and dry cups applied on the right side of the chest. The patient improved rapidly. Bv October 19th, the wounds were healed, and he was returned to duty. He was discharged on March 26th, 1864. A consid- erable portion of the sternum had exfoliated. Examining Surgeon William D. Scarff examined the man on July 27th, 1864, but gives no additional information. Case. — Private John Kearney, Co. G, 69th New York Volunteers, was wounded at Malvern Hill, July 1st, 1862, a bullet striking his chest, about two inches to the left of the median line, at the fourth rib, and lodging in the lower portion of the body of the sternum. Various efforts were made to remove it by counter openings, but iu vain, and, after nine months in general hos))itals iu Washington and New York, he was discharged, as unfit for service. The wound had healed to a certain extent, and he went to work at his trade of shipwright. He reenlisted in February, 1864, the wound, at the time of examination, presenting the ordinary a])pearances of old gunshot wounds. He was immediately sent to EikeFs Island, New York Harbor, where he underwent a great deal of unnecessary exposure to the elements, and also to other deleterious intiuences for which that depot was, at one time, notorious. The wound broke out afresh, the surrounding parts became swollen, red, and painful, and an attack of broncho-pneumonia was superadded. An examination, by Nblaton’s probe, indicated the nature and position of the bullet, the existence of which had been previously dovbted or denied. It was removed, without difficulty, by simple incision. No spiculae of cai'ious bone were found loose, though the sternum exhibited a depression corresponding, in some measure, to the size of the bullet. About an ounce of foetid pus was discharged fi’om the surrounding tissues. The inissile was contributed to the Army Medical Museum, with the foregoing account, by Surgeon William O'Meagher, 69th New York Volunteers. It is shown in the adjoining wood-cut. Not a pensioner. Fig. 208. — A flat- tened conoidal musket bail successfully re- moved from the ster- num. Spec. 1558, .Sect. 1, A. M. JI. Ca.se. — Private J. E. A- -, Co. I, 32d New York Volunteers, having been wounded in front of Eichmond, on June 25th, 1862, was sent to Washington, and admitted into Mount I’leasant Hospital. The sternum was transversely fractured at the articulation of the third and fourth ribs by a round ball, which did not penetrate the chest. The wound was perfectly round, and from the first showed no healthy action, being covered with a thick, unhealthy slough, accompanied by a copious, foetid discharge, and inffammation of the surrounding tissues. The administration of tonics and stimulants, and the application of cold-water dressing failed to avert the fatal issue, which occurred on August 1st, 1832. The autopsy revealed destruction of the costal cartilages in the vicinity of the wound, which was about two inches in diameter, and ulceration of the mediastinum beneath. There were very fine adhesions of the pleural to the thoracic parietes, particularly of the right side ; the heart was considerably hypertroiihied, and showed evidence of fatty degeneration. The fractured sternum, shown in the adjoining wood- cut (Fig. 209), was contributed to the Army Medical Museum, with the history, by Assistant Surgeon C. A. McCall, U. S. A. Case. — Private Chalkley Berry, Co. I, 28th New Jersey Volunteers, aged 24 years, was wounded at Fredericksburg, December 12th, 1832, by a ball, which, entering the back on the right side, within a half inch of the vertebral column, opposite the spinous process of the sixth dorsal vertebra, and apparently ))assing upward beneath the scapula and over the shoulder, fractured the right clavicle just within the coraco-clavicular ligament, making a complete transverse fracture, and lodging in the soft tissues below and in ii vertical line with the point of fracture, where it was readily recognized. He was treated in the field hospital of the 2d division. Second Corps, and on the 18th was transferred to the Presbyterian Church Hospital, Georgetown ; on December 30th, 1832, to Harewood Hospital, Washington, and, on January 31st, 1863, to Broad and Cherry Streets Hospital, Philadeljihia. When admitted, the wound of entrance had entirely healed, and firm union had taken place at the seat of fracture, the inner fragment overlapping. The patient stated that, a few days after the reception of the injury, he spat a small amount of clotted blood, and continued to do so at intervals for two days, after which it entirely ceased. He also had some difficulty of respiration for a short period but was not treated for any disease of the lung. On February 22d, 1863, the ball was cut out by Surgeon John Neill, U. S. V. Berry recovered without any serious symptoms at any time, and was discharged from service on March 12th, 1863. The missile, represented in the adjacent wood-cut (Fig. 210^, was a musket ball, notched at the apex, and grooved on the side. It was contributed, with the history, by the operator. Not a pensioner. Fio. 209. — Sternum trans- versely fractured by a round ball. Spec. 84, Sect. I, A.M.M. Fig. 210. — An elongated ball grooved by impact on the clavicle. Spec. 378, .Sect. I, A. SI. M. Sect. II.] NON-PENETRATING INJURIES OF BONES. 475 Ca.se. — Private William A. Furbusli, Co. G, 16th Maine Volunteers, aged 18 years, was wounded at Fredericksburg, Virginia, December 13tli, 1862, by a ball, which struck about the junction of the external and middle thirds of the right clavicle, passed downward, backward, and inward, and emerged some inches below the spine of the scapula. There was some comminu- tion of the external part of the clavicle, and the direction of the ball made it certain that injury had been inflicted in the scapula. He was treated in the field, and, on the 18th, sent to St. Aloysius Hospital, Washington. When admitted, there were symptoms of pneumonia, though otherwise there was no evidence of injury to the lung. Soon afterward, persistent diarrhoea set in, which, with profuse suppuration from the wound, gradually prostrated him. Some detached pieces of bone were removed, and the sharp ends of the clavicle taken off. Supporting treatment. Death resulted on January 13th, 1863. Necropsy : Aside from the injury of the clavicle, the coracoid process was found entirely detached, the spine of the scapula fractured along the line of its junction with the body, the ball having struck at the junction of the spine and body, carrying away spiculaj from both. On opening the joint an interesting complication was found, not suspected during life. The cartilages were eroded, and the head of the humerus presented a c;irious appearance, and, at one point, looked as if it had been injured by some detached fragment. From this ])oint, there was free communication with the wound, admitting a flow of pus into the joint. There was no opening in the cavity of the chest. The right pleura-pulmonalis was covered with lymph. Both lungs were congested posteriorly, and a small superficial abscess was found in the inferior lobe of the right. Liver considerably enlarged but otherwise healthy. The pathological specimen is No. 720, Section I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon Alexander Ingram, U. S. A. Several hundred cases were returned as non-penetrating gunshot fractures of the ribs, but without adequate evidence that the costal and visceral pleurae and the pulmonary parenchyma had absolutely escaped injury. Shot Fractures of the Scapula . — The two following abstracts relate to cases of frac- ture of the scapula, in which the thoracic cavity was not opened primarily, but consecutive pleuritis or pleuro-pneumonia, and empyema resulted from the injuries: Case. — Private J. P , Co. H, 14th Indiana Volunteers, aged 24 years, was wounded at Antietam, on September 17th, 1862, and was admitted to hospital at Eredei’ick on September 27th. A ball had entered at the spine of the right scapula, and emerged just below and ])osterior to the acromion process of the same side, fracturing the entire spine and comminuting it to a great extent. On October 14th, the posterior wound being enlarged by an incision, two inches of the spine of the scapula was removed, and its body found to be fractured to some extent. Subse- quent treatment consisted in the application of lead-water and laudanum to the wound, and the administration of tonics and stimulants. The case progressed favor- ably. On November 2d, the wounds were reopened to allow the evacuation of pus, and a tent of oakum smeared with resin cerate was introduced. On Novemb(‘r 6th, it was discovered that the capsular ligament was destroyed ; the patient was seized with chills; his general condition failed, and he died of pleurisy, with effusion, on November 15th, 1862. The autopsy revealed extensive pleurisy, with effusion over the left side; a considerable quantity of pus in the vicinity of the scapula, and the absence of cartilage from the head of the humerus, wliich had undergone slight necrosis about the head and anatomical neck. The fractured scapula, having the upper third of the humerus attached, was contributed to the Army Medical Museum, with the history, by Acting Assistant Surgeon W. W'’. Keen, jr., and is figured in the adjoining wood-cut (Fig. 211). [See also Fig. 204, p. 564]. Ca.se. — Private F. T , Co. D, 5th New Jersey Volunteers, aged 46 years, was admitted to Caiwer Hospital, Washington, on May 9th, 1863. He had been wounded, on the 3d, at the battle of Chancellorsville. The shock to the system had been very severe. lie was conveyed to the 1st division hospital of the Third Corps, and his wound, attend(‘d by great laceration of the soft parts, was dressed under the direction of Surgeon J. S. Jameson, 86th New York Volunteers. When the patient rallied he was sent to Washington on an hospital steamer. A fi-agment of shell had struck the back, over the right scapula, causing a com])ound com- minuted friicture. The wound was closed with sutures, and a linseed poultice apj)lied; the patient was allowed sixteen ounces of wine in the twenty-four hours, and half diet. Brandy and (piinia were subsequently pre.scribed. Death occurred on May 12th, 1863. At the autopsy, the tissues surrounding the wound were found to be involved to a very considerable extent; serous effusion had taken place, and a collection of pus was found below the neck of the scapula. The extent of the injury to the bone is shown in the adjoining wood-cut (Fig. 212). The spine and a large portion of the dorsum of the scapula are carricid away, and a fissure extends into the glenoid cavity. The extremity of the acromion process, separated from its attachments, is present, but is misplaced in the cut. The specimen wi^s contributed tured by a fnigment of shell. A>ec. 1217, Sect, to the Army Medical Museum, with the history, by Surgeon O. A. Judson, U. S. V. > ■ • • Fio. 211. — Scapula and portion of hmnenis 476 WOUNDS AND INJURIES OF THE CHEST. [ClIAl>. V, In a third case of shot fracture of the scapula, the complications were probably due to embolism rather than to the extension of inflammation by contiguity : Case. — Private W. F , Co. F, 18th Massachirsetts Volunteers, aged 30 years, was wounded at Bull Run, August 30th, 18G2, and was admitted to hospital at Alexandria, on the following day. There was a wound of the left .arm, about four inches below the acromion process of the scapida, to which cold water was applied. On the 3d, and again on the 5th of September, frag- ments of the ball, with a few pieces of comminuted bone, were removed through an incision on the outer edge of the scapula, affording the patient considerable relief. A profuse discharge from the wound soon followed, and on the 19th, symptoms of purulent infection set in. An active treatment by stimulant, quinia, iron, and ammonia, was instituted, but unavailingly. Death resulted on Septem- ber 25th. The necropsy showed a fracture of the head and dorsum of the scapula, extending below and parallel to its spine. A large collection of extravasated blood was found beneath the scapula and between the muscles of the shoulder, which were disorganized, and of a greenish hue. There was extensive serous effusion in the left pleural cavity, and numerous metastatic foci in both lungs. The fractured scapula, with two fragments of ball attached, and having upon its venter a thin layer of friable, yellowish exudation, was contributed to the Army Medical Museum by Acting Assistant Surgeon W. H. Fig. 213.— Left scapula, showing a fracture, nearly Butler, and is figured in the adjoining wood-cut (FiG. 213). pjirallel with the spine of the scapula, with two fragments of a conoidal musket-ball. Spec. 178, Sect. I, A . M. M. Internal Injuries without External Wounds.— The third and last subdivision of non- penetrating gunshot injuries of the chest, comprises those infrequent cases in which lesions of the contents of the cavity are produced without fracture of the bony or cartilaginous case or even solution of continuity in the soft parts. The pension returns would indicate that such accidents were not uncommon ; but the instances in which the diagnosis of the internal lesions has been made out with precision at the time of the reception of the injury are very rare. The truth is that the severe contusions by large spent shot, causing ruptures of the lung and heart, or laceration and great extravasation, are fatal on the field, and very rarely came under the surgeon’s observation, while the slight concussions of the contents of the chest cavity often pass unnoticed : Case. — Private H.arry Morris, Co. A, 115th Pennsylvania Volunteers, aged 24 j'ears, was wounded at Gettysburg, July 1st, 1803, by a large spent fr.agment of shell, which caused a very serious concussion of the left chest. He was conveyed to tho hospital of the First Corps, where ho remained until the 24th, when he was transferred to Camp Letterman Hospital. On admission at C.amp Letterman, the patient’s condition was very low. There was extensive ecchymosis of the left side, and he was troubled with cough and dyspnoea, and was unable to take any solid food. There appeared to be extensive inflamm.ation of the left lung. Cough .mixtures, tonics, and stimulants were administered, and the chest was rubbed with a stimulating lotion. On the 27th, he rtiised some bloody matter with difficulty. He gradually sank, and died on August 3d, 1863. There was no oppor- tunity of making an autopsy. Assistant Surgeon C. A. Hamilton, 76th New York Volunteers, reports the case. Case. — Private H. H. Bonham, Co. F, 7th Wisconsin Volunteers, aged 17 years, was wounded atthe Wilderness, Virginia, May 7th, 1864, by a fragment of shell, which struck the left breast near the sternum, two inches below the clavicle. Tho cavity of the chest was not opened; but there was lesion of its contents by contusion. He was carried to the hospital of the 4th division. Fifth Corps, and a simple bandage was placed about the chest. On May 11th, he was transferred to Harewood Hospital at W'ashington; on the 15th, to Cuyler Hospital, Germantown, whence he returned to duty on July 5th, 1834. Discharged from service on August 7th, 1865. Pension Examiner J: H. Hyde, M. D., reports. May 23d, 1833, that Bonham “suflers from palpi- tation of the heart. He expectorates blood, and has almost entirely lost the use of his left arm.” Case. — Corporal Joseph Kiukade, Co. B, 68th United States Colored Troops, aged 25 years, received a contusion of the chest, with internal injury, caused by the bursting of a torpedo at Fort Blakely, Alabama, April 10th, 1835. On the 15th, he was adinitt(*d to the Corps d’Afrique Hospital, New Orleans, and simjile dressings applied. lie recovered and was discharged from service on Juno 17th, 1835. Surgeon Francis E. Pi(|uette, 86th United States Colored Troops, reports the case. Case. — Corjioral William H. Mix, Co. H, 2d New Hampshire Volunteers, aged 22 years, received a contusion of the left side of the thorax by a cannon ball, at Gettysburg, July 2d, 1833. He was taken to the field hospital of the Third Corps, where he remained until the 11th, when he was transferred to Summit House Hospital, and on the 23th, to Mower Hospital, Philadelphia. H e stated that when hit his breast was protected by a book and blanket. Blood was discharged from the lungs, in considerable (luantities, for live days after the reception of the injury. When admitted, the patient rested badly and complained of pain in the injunHl breast ; he expectorated considerable muco-purulent matter. Volatile liniment was applied with fi iction. He improved rajiidly, and, on Seiiteinber 25th, 1863, was returned to duty. Surgeon J. Hopkinson, U. S. V., reported the case. • Sect. II.] INTERNAL INJURIES WITHOUT EXTERNAL WOUNDS. 477 Case. — Private Dominick Barrett, Co. D, 6tb Indiana Volunteers, aged 42 years, was wounded at Dallas, Georgia, May 27tli, 1864, by a conoidal ball, wbicb struck the thorax anteriorly, producing a very serious concussion of tlie lung without external injury ; be also received a wound of the band. He was carried to the hospital of the 3d division. Fourth Corps. On June Gth, he was transferred to Totten Hospital, Louisville; on July 3d, to the hos])ital at Madison, Indiana, and on September 17th, 18G4, to Indianapolis, for muster out of service. Not a pensioner. Surgeon A. C. Swartzwelder, U. S. V., reports the case. Case. — Sergeant Heni’y Alic, Co. A, 12th United States Infantry, was admitted to llarewood Hospital, W’ashington, May Gth, 1863, with a contused wound of the left side of the chest, received at the battle of Chancellorsville, on May 3d. A cannon ball of spent force struck the chest between the fifth and twelfth i-ibs, discoloring the whole side fif the chest. The patient expectorated a large amount of blood, and sufiered greatly from dyspnoea and other symptoms of injured lung. He gradually improved, and was returned to duty on July 28th, 1863. Not a pensioner. Surgeon Thomas Antisell, U. S. V., reported the case. Case. — Private Henry Bloss, Co. A, 31 Michigan Volunteers, aged 28 years, received an injury of the lung by concus- sion of the chest from a large fragment of shell, at the WTlderness, May Gth, 1864. He was treated in the field until May 24th, when he was transferred to Harewood Hospital, W^ashington. Anodynes were administered and rest enjoined. On February 20th, 186.5, he w’as transferred to the Post Hospital at Camp Chase, Ohio, and, on February 25th, to Tripler Hospital, Columbus, whence he was discharged from service on April 10th, 1865, on account of expiration of term of service. Acting Assistant Surgeon C. A. Perdue reports: “In this case there is a tendency to mental aberration. The lung is in a bad condition.” Case. — Private James Lloyd, Co. G, 1st New Jersey Cavalry, aged 26 j'ears, received a severe contusion of the chest, with laceration of the lungs, by a solid shot, at Sailor’s Creek, Virginia, April Gth, 1865. He was at once conveyed to the field hospital of the 2d division. Cavalry Corps, where morphia was administered. On the 12th, he was transferred to the Ninth Corps Hospital; on May 7th, to Armory Square Hospital, Washington, and on May 27th, to Whitehall, Pennsylvania, whence he was discharged on June 23d, 1865. He is not a pensioner. Assistant Surgeon E. .1. IMarsh, U. S. A., reports the case. Seventeen other cases, believed to belong to this group, were received at the field hos- pitals. Thirteen terminated fatally in from twelve hours to four days from date of injury. Unfortunately, the notes are very brief, and no autopsies were made. But the experienced surgeons who observed these cases would not have discriminated them in their reports on trivial grounds, and the mention of the existence of pneumothorax or hemothorax or profuse hemoptysis as attendant symptoms, and of pleurisy and pneumonia in the survivors, indicate that these cases were regarded as lesions of the contents of the thorax without external breach of surface. M. Gosselin* suggests, as the probable mechanism of this lesion, that the lungs being distended in inspiration, and the glottis being spasmodically closed at the moment the external violence is applied, the pulmonary tissue must rupture, if the force is great enough, as it cannot yield. This is, doubtless, the true explanation in the cases to which this writer restricts his inquiries, but is not required in those instances in which the lung is lacerated by fractured ribs, the integument remaining intact, Mr. Le Gros Clark [Lectures on the Principles of Surgical Diagnosis, 1870, p. 210) believes that a condition of “serious functional derangement, without organic lesion,” is sometimes the result of external violence, and proposes the name of concussion of the lung for this condition, from its analogy to concussion of the brain. He frankly admits, however, that he is “unacquainted with any special diagnostic sign by which to recognize it apart, that is, from the general indications of disturbed function, and possibly local pneumonia, unless we may accept as evidence the secondary expectoration — usually after the lapse of forty-eight hours — of blood-stained niucys, where no pneumonia exists.” * GOSSELIX, I., liechercJies sur les Dechirures du Poumon sans Fractures des Cotes correspondayites^ en Mem. de la Soc. de Chir., Paris, 1847, T. J, p. 201 ; IlEWSOX {Med. Ohs. and Inq.^ Vol. Ill, p. 372) appears to have first called attention to this particular point in chest injuries. lie cites examples from Mery {Mem. de V Acad. Royale des Sciences^ 1713), and ClIESTON, {Path. Inquiries from Dissec. of Murh. Bodies, Gloucester, 177(5). Laenxec, in describing pneumothorax, quotes IlEWSOX. UUESCHET {Diet, des Sci. Med., Paris, 1815, T. XII, AUT. Emphyslme), JIUKAT {Nouveau Diet. dcMid., Paris, 1842, Art. Emphyseme), and BOYEU {TraiU, 5th ed.), allude to the possibility of the accident under consideration. GOSSELIN enters fully into the subject and cites cas<»s reported by ROQUES {Arch. gin. de Med., 1829), Saussier {Theses de l^aris, 1841), Smith, {Dublin Quart. Jour., 1840), Paillaru {Legons OraUs of DUI’UYTREX, T. VI, p. 308), and Latargue {Jour, de Med. de Bordeaux, 1840, p. 105). Paillard's cases alone were examples of gunshot injury. They are detailed in his Relation of the Surgery at the Siege of .\ntwcrp, where he gives also (p. 22) the interesting case of (Captain Coultault, an engineer officer, struck in the trenches at Antwerp, by a large spent cannon ball, over the lower lateral portion of the chest, and almost instantly killed. The clothing and integuments were uninjured ; but Professor FORGET found five ribs fractured, with such comminution as to jicnnit the hand to be passed behind the skin and pulpified subjacent soft parts, far into the cavitj’ of the thorax. Jorert {Plaies d' Armes d feu, pp. 1(52, 109) gives a good account of this form of injury for the militar}* surgeon. lie does not exclude the cases in which the ribs are fractured, as does M. GossELIN. Professor 8. J>. GROSS {S jst'im, 5th cd., Vol. II, p. 444) accepts M. Go.sSEUX’s explanation of the accident, as docs Dr. .JOHN ASHIIURST, jr. {Principles and ] Practice of Surgery, Phila., 1871, p. 375). The latter has collected si.xteca cases of this nature from the records of the surgery of civil life, including tliose observed at the Pennsylvania and Fpisoopal Hospitals, Philadelphia, by Dr. E. IlAUTSHOUXE and Dr. C. 0. Lee. 478 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, Penetrating Gunshot Wounds of the Chest. — We pass now to the consideration of a class of very serious injuries of the chest, comprising complicated lesions of the bony, cartilaginous, and muscular case composing the thorax, — the vertebrae, sternum, ribs, costal cartilages, and diaphragm, — of the contained viscera, — the lungs and pleurae, heart and great vessels and nerves, the oesophagus and thoracic duct, — and also of the clavicle and scapula, which partly protect the cavity. Of the twenty thousand two hundj.’ed and sixty-four cases of shot wounds of the chest returned in the war, eleven thousand five hundred and forty-nine have been briefly discussed in the preceding subsection as wounds of the thoracic walls, and eight thousand seven hun- dred and fifteen are to be considered here as penetrations of the cavity. Viewed in the aggregate, the ratio of mortality of cases of this category is very great, while in some of the divisions, recoveries are exceptional, and the fatality may be regarded as nearly uniform. Abstracting three hundred and twelve cases, the terminations of which cannot be traced, the death-rate of the remaining eight thousand four hundred and four is 62.5; but in the division of wounds of the heart, for example, it rises to 99.9. Hence the necessity for numerous subdivisions, in order that similar cases may be compared. Penetrating and Perforating Wounds without Fracture. — Many cases were reported of perforation of the chest, through intercostal spaces, by small projectiles, without any lesion of the bones. In the fatal cases, in which the course of the ball was traced, it was generally found to have traversed the lung, and that death had resulted from haemorrhage or from empyema. In the cases of recovery, the existence of wounds of the lung was not always determined with satisfactory precision, and, in some instances, the missile probably ran around the pleural surface of a rib or aponeurosis, without lesion of the lung substance. Such injuries are unquestionably less fatal, other conditions being equal, than those accompanied by fracture, and particularly by fracture at the entrance wound. Indeed the complications produced by the splinters forced inward are often more formidable than the lesions caused in the lung by the ball itself. § Recoveries . — Some examples of these wounds, confined to the soft parts, which had a favorable termination notwithstanding the injury to the lung, may here be cited. The first two abstracts refer to instances complicated by injury to the brachial plexus of nerves: Case. — Private Edward Parsons, Co. D, ISth New York Cavalry, aged 21 years, having been accidentally wounded at Berlin, Maryland, on .July 19th, was admitted to hospital at Frederick, on July 24th, 1863. A conoidal ball had entered at the anterior fold of the right axilla, grazed the right lung, and emerged three inches above the right nipple. The patient spat blood in small quantities, and complained of pain in the right side ; his general health and appetite were good. Wet cups were applied to the seat of pain. On July 28th, there was traumatic neuralgia of the median and ulnar nerves, which was alleviated by the ap])lication of a blister. August 3d, the neuralgia was confined to the wrist and hand. August 9th, neuralgia in the little and ring fingers only. By September 10th, the patient was much improved, but had dyspnoea on exposure. He was discharged the service on December 9th, 1863, at which time the neuralgia had entirely subsided, leaving the wrist and hand slightly rigid. On December 17th, 1863, Pension Examiner Charles Rowland reports, “this soldier is totally disabled; his forearm is at present entirely useless, hut will improve and finally recover.” A communication from the Commissioner of Pensions, May 5th, 1868, informs us that this man’s claim for pension was rejected, there being no evidence of his being wounded in the line of duty. Case. — Private John Couthard, Co. D, 123d Indiana Volunteers, aged 21 yeai-s, was wounded, at Kenesaw, Georgia, June 17th, 1864, by a conoidal ball, which passed through the soft part of the left arm, entered the thorax between the fifth and sixth ribs, passed through the posterior portion of the left lung, and emerged between the sixth and seventh ribs, three inches from the spine. He was treated in the field, and, on July 1st, sent to the hospital at Knoxville, Tennessee. Simple dressings were applied to the wound. He received a furlough on .July 26th, at the expiration of which he reported to Washington Park Hospital, Cincinn.ati, Ohio. Discharged from service on January 2d, 1865. Pension Examiner Edward Mead reports, the day after discharge, that “the ball entered upjter third of left arm, passed inward and entered the u|)per portion of left lung and out at right side of spine in dorsal region. Gangrene followed, leaving a large cicatrix. Haemoptysis continued, as alleged, until three weeks ago. Hand is paralyzed .and action of shoulder limited. Probable fracture of spinous ])rocesses of two dors.al Sect. II.] PENETEATING SHOT WOUNDS WITHOUT FRACTURE. 479 vertebrae. Arm nearly useless. Functions of lung impaired. Disability total and permanent.” Pension Examiner W^illiam Owens reports, September 25tli, 1866, that the pensioner’s health was good. The lung can be fully inflated, but gives indications ot weakness in talking, walking, or running briskly. No haemorrhage has occurred for a year past. Pension Examiner John L. Neilaun reports, November 30th, 1869, that the brachial plexus is injured, consequently paralysis of arm. The left arm and shoulder are shrunken, and he has very imperfect use of the hand, although the forearm seems well developed. The left shoulder is depressed and the pectoral muscles wasted. Auscultation shows nothing more than bronchial mucous rales. Numbness of hand and imperfect circulation. Pain at seat of wounds is aggravated by cold or stormy weather. The Pension Examining Board, consisting of Drs. McEeynolds, White, and Conner, reports. May 4th, 1870, that the “ball entered inside of left deltoid and passed out of right side of spine, * * injury of median nerve, * “ two inches expansion of chest, respiration a little rude, * * wound of median nerve.” Case. — Corporal Joseph J. Young, Co. D, 1st Minnesota Volunteers, aged 34 years, was wounded at Antietam, Mary- land, September 17th, 1862, by a musket ball, which entered the chest between the fourth and fifth ribs, one and a half inches from the sternum, passed through the right lung, and emerged at the lower and anterior edge of the right scapula, the ball having glanced on striking the scapula. He was treated in the field, and, on September 21st, transferred to the hospital at Frederick. Maryland. When admitted he was in a very debilitated state, having lost much blood. There was slight pneumonia, which soon subsided. Htemorrhage from the wound occurred daily. A supporting treatment was adopted. Erysipelas supervened October 16th, but subsided under the application of a solution of lead and opium. On December 27th, he was transferred to Falmouth, Virginia, and discharged from service on January 1st, 1863. Pension Examiner A. E. Ames rej)orts. May 25th, 1867, “wound opening and frequently discharging. Is much troubled with pain in region of liver. Disability permanent and equal to loss of limb.” No later report at the Pension Office, except that the pensioner had removed to Oregon, and was last paid at San Francisco, September 4th, 1871. Case. — Private Samuel Graves, Co. B, 7th Kansas Cavalry, was wounded at Arkansas Post, Arkansas, January 11th, 1863, by a pistol ball, which entered above the right nipple, passed through the lung, and emerged below the right scapula. Free haemoptysis occurred directly upon injury. Sputa were bloody for a long time. He was admitted, on January 23d, to Adams Hospital, Memphis. Being of a feeble constitution, naturally, he did not gain strength rapidly. He was discharged from hospital about April 1st, 1863, at which time he complained of a tightness of the thorax, preventing him from taking a full inspiration. There was probably an adhesion of the lung both at the anterior and posterior perforation. Both the external wounds had entirely healed. He had very little cough and no bloody sputa. He is not a pensioner. In reporting the following case, Surgeon D. C. O’Keefe* remarks: “This case presents two points of deep interest. The first is that of an unquestionable wound through the lung without any symptom indicating that injury, except the original haemoptysis. The second was the undoubted severing of the left subclavian artery, as indicated by the absence of pulsation in the radial or brachial artery, which was carefully and frequently sought for, and of the absence of which there could have been no mistake:” Case. — Sergeant Cyrus L. Nabors, Co. F, 2d Arkansas Regiment, aged 29 years, constitution good, occupation farmer; wounded on May 19th ; admitted to the Institute Hospital, Atlanta, May 20th, 1864. Gunshot wound by minie ball, which entered posteriorly two and a half inches to the left of the spinal column, opposite the body of the fifth dorsal vertebra, and, pa.ssing obliquely forward, made its exit between the third and fourth ribs, at a point three inches to the left of the sternum. Alarming haemorrhage and haemoptysis followed the receipt of the injury. On admission, the patient was greatly debilitated from haemorrhage ; there was neither cough, constitutional disturbance, nor haemoptysis; no pulse could be felt at the wrist in the radial artery of the affected side, nor in the bracial as far as the axilla. From admission, this patient continued to do well without a single bad symptom. The arm on the wounded side was considerably atrophied and somewhat paralyzed, due, doubtless, to the cutting off of the supply of blood and nervous influence. June 30th, doing well ; furloughed home. Case. — Private .Joseph Forrest, Co. F, 13th Missouri Cavalry, aged 21 years, was wounded at Osage, Missouri, October 25th, 1864, the ball entering at the outer margin of the left axilla and penetrating the thorax. He was admitted to the hosj)ital at Fort Scott, Kansas, on the next day and water dressings were applied to the wound. Discharged from service April 27th, 1865. Pension Examiner Julian Bates reports, June 7th, 1865, that “the ball is believed to be still lodged in the chest. The pensioner suffers from cough and disturbed respiration through the chest, and is greatly emaciated.” He imj)roved afterward, and his pension was discontinued on March 3d, 1869. Shot Penetrations of the Chest with Lodgment. — In the four following cases missiles deeply penetrated, traversed the thoracic cavity, and lodged within it: Case. — Private Ludwig Kuhn, Co. D, 26th Wisconsin Volunteers, aged 24 years, very robust, having been wounded at Gettysburg, on .July 1st, was sent to Philadeljdiia, and admitted to Satterlee Hospital on July 9th, 1863. A conoidal musket ball had entered to the right of the inferior angle of the right scapula, j)enetrated the thoracic cavity and lodged. For s(!veral days after the reception of the injury, there was haemoptysis, which isre[)orted to have ceased after the ))atient was bled from the left arm. The remaining treatment consisted of cold-water dressings, linseed poultices, and cerate dressings to the wcunid after ^Confederate. States Medical and Surgical Journal, Uichmond, 18U5, Vol. II, No. 2, p. 33. 480 WOU^IUS AND INJUKIES OF THE CHEST. [Chap. V, the reniov'al of the ball. There were no serious symptoms during the progress of the case, and but slight indication that the lung had been penetrated. The patient had nearly recovered his health by December 31st, 18G3, when he was transferred to the Veteran Eeserve Corps. He was discharged from service on June 9th, 1864, and subsequently enlisted in Co. I, 214th I’eunsylvania Volunteers. During his second enlistment he was treated in the hospitals at Washington and Philadelphia. •The patient stated that his wound was so painful as to deprive him of re.st, and he was unable to lie upon his back. The wound had healed, with the exception of a fistulous opening, and the constitutional condition was good. In February, 1866, Pension Examiner James Neil reports “there are pleuritic adhesions and partial consolidation of the lung. The patient looks well.” C.VSE. — Captain Theodore A. Hope, Co. E, 91st Pennsylvania Volunteers, aged 26 years, was wounded at Five Forks, \ • Virginia, March 31st, 1835, by a conoidal ball, which entered the right chest three inches above the nipple, between the second and third rib.s, passed downward through the lung, and lodged in the left side of the diaphragm. Haemoptysis occurred on the reception of the injury. He was taken to the hospital of the 1st division. Fifth Corps, where he remained until April 29th, when h(i was transferred to Armory Square Hospital, Washington. There was pneumonia of right side when admitted. Poultices were applied to the wound, and anodynes and stimulants given. Morphia, in half-grain dose.s, was given hypodermically twice a day. On .June 1st, the patient vomited a large amount of bilious matter, which would also flow from the wound after a short cough. On August 19th, he was transferred to Douglas Hospital, Washington, and on the 30th to Mower Hospital, Philadelphia, whence he was discharged from service on October 28th, 1865. Pension Examiner .1. H. Gallagher reports, February 14th, 1866, that “walking and exercise cause lancinating pains in the chest, and dy.spnoea. There is constant dull heavy pain in the left side, at the point of lodgment of the ball. In dull and changeable weather he is weak and depressed; countenance distressed.” No further report to March, 1872, when the Captain was still an invalid. Case. — Priviite John Fonts, Co. D, 5th Ohio Volunteers, aged 17 years, was wounded at Dallas, Georgia, May 27th, 1864, by a musket ball, which entered the posterior part of the thorax, two inches to the left of the spine, and" on a levml with the nipple, penetrated, and lodged within the chest. Jle was treated in the field hospital of the 2d division. Twentieth Corps, and on .Tune 4th, sent to No. 1 Hospital, Nashville. On June 7th, he was transferred to Totten Hospital, Louisville, and on June 24th, to Camp Dennison Hospital, Ohio, whence he was transferi-ed to the VetcT’an Reserve Corps on November 29th, 1864. Di.scharged from service on .July 26th, 1865. Pension Examiner Adams Jewett states that he examined Fonts, August 26th, 1865, and “noticed nothing abnormal on c.areful auscultation and percussion. Respiration 24. Pulse 93, and regular. Complained of occasional attacks of dyspnoea.” Case. — Private John Howard, Co. I, 148th Pennsylvania Volunteers, aged 35 years, was wounded at Gettysburg, July 2d, 1863; the missile struck the left hand near the palmar end of the third finger and passed out near the palmar end of the thumb; it then entered the chest two inches above the left nipple, pas.sed through and lodged near the inferior angle of the left scapula. He was conveyed to the field hospital of the Second Corps, where he remained until the 15th, when he was transferred to McKim’s Mansion Hospital, llaltimore. Cold-water dressings and poultices were applied to the wounds. On Jidy 22d, the missile was extracted by Surgeon L. Quick, U. S. V. August 13th, wound of hand doing well; that of chest healed externally. He was transferred to Cuyler Hospital, Germantown, Pennsylvania, October 2d; to Camden Street Hospital, Baltimore, November 2d, and to the Veteran Reserve Corjis, November 12th, 1833, with which corps he served until discharged from service on August 14th, 1865. The missile, an elongated smooth-bore ball, notched at the apex and compressed at the base, was forwarded to the Army Medical Museum, with a history of the case by the operator, and is represented in the adjoining wmod-cut (FiG. 214). Pension E.xaminer William .1. McKnight reports, September 5th, 1865, “the fingers are all cro(dved and deformed permanently, and the spine inuscle injured ; a b.ad case. Disability total.” In March, 1872, the pensioner’s name was on the rolls, his condition reported as little changed in the eight years succeeding his injuries. § Fatal Cases . — The following abstracts relate to fatal penetrations of the lung through intercostal spaces. In these it is to be regretted that the post-mortem appearances are not fully described: Fig. 214. — Ball extracted from soft parts near lower .angle of left scapula. Spec. 1519, Sect. I, A. M. M. 0_.VSE.— Private John Vexter, Co. D, 98th Pennsylvania Volunteers, aged 40 yeais, was wounded before Petersburg, Vii’trini.a, June 7th, 1864, by a conoidal ball, which passed directly across the neck. He also received a gunshot fracture of the lower jaw, and a penetrating wound of the chest. He was taken to the hospital of the 2d division. Sixth Coi-ps, and, on .June 10th, was sent to Emory Hosiiital, Washington. The wounds were cleaned and iced-water dressings applied, with stimulants, expectorants, anodynes, and nourishing diet internally. When admitted, the patient was much exhausted from loss of blood and exposure; respiration dilBcult ; pulse 83, and irritable cough and orthopnoea. By June 11th, the patient hreathcd easier and was able to lie down. The swelling was subsiding, and the wounds discharging slightly. He was unable to swallow any- thing except liquids. On June 13th, the breathing became more difficult, and, on the 14th, the wound of the chest commenced discharging slightly, blood and air passing from the orifice. Death resulted on June 15th, 1864. Case. — Private Frederick Livinhagen, Co. B, 95th New York Volunteers, aged 25 years, was wounded at Petersburg, Virginia, April 1st, 1865, by a conoidal ball, which entered the left side and penetrated the lower lobe of the left lung anteriorly through the fourth intercostal space. He was treated in the field, at the hospital of the 3d division. Fifth Corps, in charge of Surgeon A. S. Coe, 147th New York Volunteers. There was hmmoptysis anil some difficulty of respiration; but it was not urgent. The wound was left open for the escape of secretions. Afterwards there was considerahle ))neumonic inflammation. Demulcents, slight anodynes, and low diet, with absolute rest, constituted the treatment. His condition improving somewhat, and the hospital being overcrowded, the patient was placed on a hospital steamer, and, on April 10th, was sent to Armory Square Hospital, Washington. Pymmia supervened, and death resulted on April 17th, 1835. Sect. II.] PENETKATING SHOT WOUNDS WITHOUT FRACTURE. 481 Case.— Sergeant Daniel O'Shea, Co. K, 28th Massachusetts Volunteers, aged 29 years, strong and plethoric, received a jienetrating wound of the thorax, by a musket ball through the third intercostal space, at Deep Bottom, Virginia, on July 27th, 1834. He had htemoptysis, hurried respiration, anxiety of countenance, and sharp pain at the seat of injury. Simple dressings were d^plied at the field hosi>ita] of the 1st division of the Second Corps, and cool drinks, with a little. morphia to quiet the harassing cough, were prescribed. It was necessary to remove him by rail to City Point, whence he was sent to Wasliiugton hv hosintal steamer, and admitted to Lincoln Hospital on July 30th, 1864. Tonics, stimulants, expectorants, and arterial sedatives were administered ; dry and wet cups and blisters were applied, and a nourishing diet was allowed. The patient died on the afternoon of August 11th, 1864, of pneumonia. At the autopsy, sixteen hours subse- quently, a penetrating wound of the anterior surface of the upper lobe of the right lung was found ; the heart weighed fifteen ounces and a half, and the cada ver was in such an advanced stage of decomposition that the dissection was not prosecuted farther. Acting Assistant Surgeon H. M. Dean reports the case. Case.— Private B. A , Co. D, 151st Pennsylvania Volunteers, aged 19 years, was wounded at Gettysburg, July 2d, 1863. A ball passed through the left wrist and another through the upper part of the left lung. He was admitted to the field hospital at Gettysburg, and, on July 9th, transferred to McKim’s Hospital, Baltimore. He was placed on full diet, with ale and ten drops of tincture of sesquichloride of iron thrice daily. The wound of the wrjst becoming unhealthj’ in character, necessitated amputation of the forearm of the middle third. On August 31st, the patient was taken with pyaemic symptoms, and was ordered cinchona, with beef tea and milk-punch. On September 1st, the general condition was much worse, and the exhalations from the lungs and skin were very offensive. The stomach was irritable, and vomiting was not arrested by the administra- tion of morphia in small doses, lime-water, etc. The patient continued to sink, and death occurred on September 6th, 1863. The perforated portion of the lung was contributed to the Army Medical Museum, with this history, by Medical Cadet W. H. Bradley. (See Fig. 215.) Fig. 215. — Portion of the left lung perforated by a bullet. Spec. 1798, Sect. I, A. M. M. Collapse of the Lung . — The two following examples of collapse of the lung after gun- shot perforation, presented the usual phenomena of extreme dyspnoea, feeble pulse, pallor of countenance, clammy skin, inability to lie on the sound side, absence of respiratory murmur and alteration of the percussion sounds on the wounded side: Case. — Private Joseph Barnham, Co. A, 125th New York Volunteers, was admitted to McKim’s Mansion Hosjiital, Baltimore, July 9th, 1833, with a gunshot penetrating wound of the chest, received at Gettysburg on the 3d. The ball entered the cavity of the thorax on the right side between the third and fourth ribs, about three inches from the median line. When admitted he was in a state of delirium. He suff'ered with dyspnoea and severe pain in the chest, unattended by cough or haemoptysis. Being unable to partake of nourishment, he sank rapidly, and died on July 12th, 1833. At the necropsy the cavity of the thorax, right side, contained about four quarts of sero-purulent fluid. The right liing was closely compressed against the vertebral column and completely solidified. The middle lobe was perforated by the ball, which was found lying loose in the lower part of the thorax within the pleura. The costal and pulmonary pleura showed evident marks of inflammation. The missile, a couoidal ball, with one side of the body obliquely flattened and grooved, was forwarded, with a history of the case, by Surgeon Lavington Quick, U. S. V. (See Fig. 216.) Case. — Private Henry J. Ricker, Co. H, 10th Maine Volunteers, was wounded at Cedar Jlountain, Virginia, August 9th, 1832, by a round ball, which entered two inches below the right acromion, passed between the second and third ribs, through the base of the right lung without injuring the large vessels, and lodged against the body of the vertebra just above the diaphragm. On the 12th, he was admitted to Fairfax Street Hospital. On admission, there was severe dyspncea. Death resulted on August 17th, 1862. The necropsy revealed the course of the ball ; the right lung was found to be completely collapsed and the pleural sac contained one hundred and twenty ounces of bloody fluid. The missile, represented in the wood- cut (Fig. 217), with a history of the case, was forwarded by Acting Assistant Surgeon James Robertson. Fig. 217. — Slightly contused rifle ball. Spec. 4403, Sect. I, A. M. M. Fig. 216. — Conoidal mus- ket-ball flattened by impact on bone. Spec. 2G43, Sect. I, A. M. M. Injudicious Probing . — The next case illustrates the hazard attending too diligent explo- rations of the wound of the lung, a danger famili’ar to the practical surgeon, but often disre- garded by the inexperienced. Mr. Poland* justly denounces such manipulative examina- tions as “perfectly unwarrantable, being attended with highly dangerous results, by dis- turbing nature’s efforts to effect a repair, disarranging the clot, and exciting irritation and inflammation; a proceeding, only tending to gratify curiosity, without the slightest benefit to the patient.” On Injuries of the Chest, in Holmes’s System, trp. cit. Vol. II, p. 579. G1 482 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, Case. — Private Albert M. Carley, Co. H, llltb New York Volunteers, aged 18 years, was wounded ae Petersburg, at the general assault, Ajiril 2d, 18C5, by a conoidal ball, ^vbicb entered the left side near the spine, between the eighth and ninth ribs, penetrated the thorax, and lodged. lie was taken from the field and sent by rail, with over two hundred other wounded of the corps, to City Point, to the field hospital of the Second Corps, under AAing Staff Surgeon John Aiken, U. S. V. lie had rallied from the shock of the injury, but was de])ressed by haemorrhage, and had labored breathing and ha,‘mo]etysis. Simple dressings were applied, and the patient was jilaced on an hospital steamer, and on April hth was admitted to Armory Square Hospital, Washington. He died on April Gth, 18G5, while the wound was being examined. Casp:. — Private Leonidas Miller, Co. A, 26th Iowa Volunteer.s, was wounded at the battle of Big Shanty, Georgia, June IGth, 18G4, the missile passing through the upper portion of the middle lobe of right lung, entering between the fourth and fifth ribs anteriorly, and lodging in the jdeural cavity. He was admitted on the same day into the field hospital of the 1st division, Fifteenth Corps, in charge of Surgeon M. W. Robbins, 4th Iowa Infantry. There was profuse haemorrhage, with greatly oppressed breathing, inability to lie in a recumbent posture, or on the sound side, with feeble pulse. The bleeding was arrested by cold applications to the chest, and opiates were given. In spite t)f supjwrting treatment he failed gradually, and was transferred to the general hospital. Fifteenth Corps, at Barton's Iron Works, Georgia, on June 29th. On admission, the patient was much emaciated and had a large bed-sore in the sacral region ; his countenance was pale and expressed great anxiety ; breathing was difficult and attended with excruciating pain; pulse 120; the wound presented externally the usual healthy appearance. Stimulants and anodynes were administered, simple dressings a])plied to the wound, and a generous diet ordered. The patient died on July 3d, 1864. The case is reported by Surgeon J. C. Hilburn, 97th Indiana Volunteers. Case. — Private Francis Smith, Co. K, 46th Ohio Volunteers, was wounded at the battle of Kenesaw Mountain, June 27th, 1864, by a conoidal ball, which entered the left chest, penetrated the fourth intercostal space near the nipple, passed through the lung, and made its exit between the sixth and seventh ribs, close to the spinal column. He was received into the field hospital, Fifteenth Corps, at Barton’s Iron Works, Georgia, on J une 30th. On admission, the patient was suffering severely. His wound was dressed and an opiate given, after wdiich he rested well for the remainder of the day. The same treatment was followed from day to day, giving him enough opium to control the pain, but he continued to sink gradually, and died on July 14th, 1864. Acting Assistant Surgeon R. H. McKay, who reports the case, says : “ In this case the patient did not seem to rally at any one time, and for a great portion of the time, during the last week, he was deliiious.” Case. — Private Jesus Garcia, Troop F, 1st New Mexico Cavalry, in attempting to escape, after being a})prehended as a deserter at Cubero, New Mexico, on October 10th, 1865, was wounded by a conoidal ball from a Remington pistol, which entered the right breast, one inch below and somewhat to the left of the nipple, passed directly through, and emerged at the inferior angle of the scapula. Another ball passed through the soft part of the outer portion of the left thigh. He was admitted to hospital at Fort Wingate. The symj)toms were excessive dyspnoea and high fever. The treatment pursued was strictly anti- phlogistic, and the patient was kept recumbent, with the shoulders slightly elevated. He died on October 13th, 1865. The ball had passed through the middle lobe of the right lung, making its exit through the seventh intercostal space. The case is reported by Acting Assistant Surgeon R. H. Longwill. Grunshot Fractures of the Clavicle. — This form of injury was usually complicated by wounds of the lung, or by fractures of the ribs or scapula, or by injuries of arteries or nerves, and the complications were frequently the most important elements of the case. A nearly uncomplicated case of gunshot fracture of the clavicle, with recovery, is detailed on page 474. All of the varieties of fracture observed in long bones are met with in the clavicle. The following is an interesting example of transverse fracture : Case. — Sergeant Samuel A , Co. F, 125th Pennsylvania Volunteers, aged 40 years, was wounded at Chancellors- ville, Virginia, on May 3d, 1863, and was admitted to Carver Hospital, Washington, on the 9th. A bullet wound was found on the right side of the back, near the spine, and in the neighborhood of the third dorsal vertebra. There was a fi’acture of the clavicle on the same side, with considerable swelling, and some deformity of the shoulder. The patient had frequent cough and bloody expectoration. The fracture of the clavicle was treated by a pad in the armpit and a sling, and the wound in the back was dressed with wet lint covered with oiled silk. Small doses of morphia were given, with the effect of diminishing very much the frequency of the cough. The patient was feeble, and the discharge fi’om the wound considerable, but no very serious symptoms })resented themselves until the 16th, when the patient was seized with considerable oppression of breathing, and with pain on the wounded side. Dulness over the upper side of the right lung was observed on percussion. A discharge of blood and sei'um from the wound seemed to relieve the pneumonic symptoms in a few hours after their first occurrence. The breathing became easier, and pain was no longer complained of. Bleeding from the wound ceased on the 17th, but a cojiious discharge of serous j)us remained, and the patient became gi-adually weaker, notwithstanding the free use of stimulants and of as much nourishment as could be administered. His sinking was slow but constant, and he died on the afternoon of May 20th. At the autopsy, the bullet was found just below the clavicle, near its middle, having fractured the bone transversely after passing between the third and fourth ribs, and fracturing the neck of the third near its angle. The specimen figured in the adjoining cut (FiG. 218), was presented to the Army Medical Museum, with the above account, by Acting Assistant Surgeon B. F. Craig. [A better view is given in the Second Volume, p. 475.] Fig, 218. — Transverse fracture of the right cla- vicle, with a conoidal bullet attached. Spec. 1210, Sect. I, A. 51. M. (Vertical view. Reduced to one-third.) Sect. II.] SHOT FEACTUKES OF THE CLAVICLE. 483 Case. — Private Andrew G , Co. I, Tjtli Michigan Volunteers, aged 21 years, wtis wounded at I'h'edericksburg, December 13tli, 18C2, by a missile, which fractured the clavicle, pas.scd through the a]>ex of the right lung, and emerged near the eighth dorsal vertebra. He was admitted to Ilarewood Hospital, Washington, on December 17th, sufl'ering from traumatic pneumonia, the more formidable symptoms of which appeared to be relieved after venesection, and the administration of tartar- emetic and morphia. On January 1st, irritative fever, chills, profuse sweating, and vomiting set in, attended with haemorrhage and foetid suppuration from the wound to the amount of four ounces. A compress and bandages were apjtlied ; stimulants and tonics administered. This hectic condition continued, with brief periods of amendment, till January 7th, 1863, when death occurred. The case is reported by Surgeon Thomas Antisell, U. S. V. In the following case of gunshot fracture of the clavicle, there appears to have been little, if any, direct lesion of the lung. Hospital gangrene, which was the scourge of the Hashville hospitals at the time, gave the coup-de-grace, as it were, at the end of sixteen weeks : Case. — Sergeant Lemuel A. J. B , Co. I, 27th Mississippi Eegiment, aged 22 years, was admitted to hospital at Nashville, on January 27th, 1864, fi-om another hos]ntal, for a gunshot fracture of the clavicle, which was thought to be united. The wounds of entry and exit being nearly healed, and the patient doing well, nothing more than simj)le dressings were required. On February 11th, the patient had a severe chill, followed by fever, cough, and pain in the chest, for which quinine and whiskey were prescribed. On the 13th, pneumonic symptoms setting in, treatment was directed to their relief. On the 15th, the wound became re- inflamed and gangrenous. On the day following, the patient being very restless and suffering much from his wound, ether and chloro- form were administered, and bromine in full strength applied. He rallied slowly, reaction being rather imperfect. Becoming more exhausted and restless, he died on the afternoon of the 17th. The specimen was contributed to the Army Medical Museum, with the history, by Acting Assistant Surgeon E. T. Higgins, and is figured in the adjoining cut (FiG. 219). [This patient was, probably, 6horteDiD|, posterior displacement, and necrosis, ^pec. 2194, Sect. wounded at Mission Eidge, November 25th, 1863, as he was received at Nashville fi’om the hospital for prisoners at Stevenson, Alabama, December 11th, 1863. A musket ball had entered at the junction of the outer with the inner two-thirds of the left clavicle, had passed downward, inward, and backward, emerging between the scapula and spine, probably injuring the pleural cavity, though the diagnosis was not made out positively. The lung trouble was mainly secondary.] Case. — Private IF. H. C , Co. H, 31st Georgia Eegiment, wounded at Fredericksburg, December 13th, 1862, was admitted to Carver Hospital, Washington, and died exhausted on January 8th, 1863. A couoidal musket ball had entered the back on the left side, about three inches from the point of the acromion process, penetrated the spine of the scapula just below the crest, passed inward and forward, and fractured the clavicle at the point where the conoid ligament is attached. From this point, its course was traced behind the large blood vessels of the neck and betvveen the oesophagus and spinal column. Here an abscess was formed which reached upward five or six inches along the spine and downward in the medias- tinum to the bifurcation of the trachea, where the ball was found point downwai-d and resting against the right bronchial tube. An opening was found commu- nicating with the abscess and the right pleural cavity. The track of the ball . and the large abscess were filled witli pus, and clots of blood undergoing puti-e- faction. Portions of the left scapula and clavicle were contributed to the Army Medical Museum, with the above account, by Surgeon O. A. Judson, U. S. V. The specimen is partly represented in the adjoining cut (Fig. 220). Case. — Private Edward Osborn, Co. H, 9th PennsyU’ania Eeserves, aged 24 years, was wounded at South Mountain, JIaryland, September 14th, 1862, by a conoidal ball, which entered the right side between the clavicle and first rib, passed through the upper portion of the lung, and emerged at the lower border of the scapula. He was taken to a farm-house and thence to Middletown, where he remained until October 1st, when he was sent to Hospital No. 3, Frederick. On January 24th, 1833, he was transferred to Hospital No. 1. When admitted, he had a severe cough ; pulse 88, but weak. Patient very much emaciated and tongue furred. Stimulants, tonics, and expectoralits were administered. January 28th : Abscess formed on posterior aspect of right arm, which was opened, evacuating about three ounces of pus. January 30th : During attempts to cough, pus escapes freely from the wound. Expectoration copious but diminishing, and sometimes streaked with blood. February 5th : Slowly improvnig. When coughing, air passes through the anterior wound, and pus through the posterior one ; discharge profuse but healthy. Cough worse when lying down and at night. February 10th : Expectoration diminished; air has cea.sed to j)ass through the wound. He continued to imi)rove, and, by February 15th, was able to move about the ward. Wound look- ing healthy and suppurating freely. On March 30th, a i)iece of bone about the size of a h;izel-nut came away from the clavicle, which had been splintered by the ball. April 18th : Eight lung almost consolidated, and sinking away of chest very noticeable. He was transfen-ed to Baltimore, and finally discharged fi'om service on November 12tli, 1863. Pension Examiner E. McCook Fig. 220. — Conoidal musket-ball, with a portion of the left scapula, which it has pertbrated. Spec. n3(). Sect. I, A. M. M. Fig. 219. — Left clavicle, showing a partially united fracture with 484 WOUNDS AND INJUEIES OF THE CHEST, [Chap. V, reports, November 18th, 1863, “ arm useless, fingers partially paralyzed. Air still passes out of the posterior opening fi’om the lung.” The Pittsburgh Examining Board reports, October 4th, 1871 : “ Gunshot wound of clavicle and lung, in consequence of which his arm and hand are almost useless, his body emaciated and feeble. Disability total and permanent; no evidence of vicious habits.” He was last paid on March 4th, 1872. A case of fracture of tlie clavicle associated with fractures of the transverse processes of the cervical vertebra is related at the foot of page 431. The Army Medical Museum contains twenty-one specimens of gunshot fractures of the clavicle. Besides those noted in the text, consult, for appearances in recent fractures of sternal and middle portions, Specs. 1644 and 2984, and of outer third. Spec. 3460, Sect. I ; for necrosis, Spec. 2193; for oblique fracture, with attempt at union. Specs. 309, 3737 ; for longitudinal fracture, Spec. 137. G-unshot Fractures of the Scapula— Several illustrations of this injury have been cited among the non-penetrating shot wounds of the chest (p. 475). But the scapula is more frequently injured in penetrating wounds of the thorax, and especially in antero-posterior perforations. A good example of the latter injury is shown by the wood-cut (Fig. 221) : Case-shot, passing from before backward through the right chest, have shat- tered the upper part of the right scapula. There are two perfoiations of the lower ])late, near its middle, connected by a fissure. The supra-spinous fossa has been chiefly carried away. The thin splintered laminas of the body of the bone are forced outward about the perforations. The specimen was contribut(‘d by Surgeon Jerome B. Green, 1st Rhode Island Volunteers. It was brought fiom the First Bull Run battle-field. Starred fractures of the body of the shoulder-blade were produced by balls entering perpendicularly from without or, in about equal proportion, by those emerging from the chest or axillary fossa. Projectiles impinging laterally or obliquely, caused longitudinal or grooved fractures, with fissures limited usually by the spine or thick border. Forms of fracture of the neck, processes, and spine, seldom or never occurring from other external violence, are not infrequent after gunshot. Thus perforations of the spine, fracture of the coracoid, and of the neck close behind the glenoid cavity, are not rare. Secondary hsemorrhages from the trunk or minor divisions of the transversalis colli, suprascapular, posterior cervical, princeps cervicis, and subscapular \vere sometimes very troublesome, the inosculations of these branches of the carotid, subclavian, and axillary perplexing the operator, and occasionally leading him in desperation to tie a vessel of the first order. Lodgment of foreign bodies beneath the scapula, and accumulations of blood and pus were more frequent and fatal complications in those cases, and it is feared that lives were lost, perhaps, from lack of boldness in their removal or evacuation. Fig. 2S21. — Gunsliot perforation of the right scapula. Spec. 851, Sect. I, A. M. M. Case. — Private John F. Scites, Co. H, 5th West Virginia Volunteers, aged 21 years, was wounded at Winchester, Virginia, July 24th, 1864. The missile fractured the first and second ribs, left side, passed backward, and slightly downward and inward, fractured the third rib about one inch external to the tubercle, and passed through the scapula at its inner border, near the middle. He was taken prisoner and retained until September 26th, when he was sent to St. John’s College Hospital, Annapolis. He was transferred, on October 6th, to Camp Parole, whence he was discharged from service on October 7th, 1864. Pension Examiner William Owens reports. May 15th, 1866, “ there is an aneurism of the left subclavian artery through the space left by the loss of portions of the first and second ribs. The left arm and shoulder are quite weak.” Examining Surgeon Jona- than Morris, Ironton, Ohio, reports, March 1, 1867, that “ujiper portion of the left lung is injured; the ball passed through left lung and left scapula; shoulder weak, and forward motion of arm painful. Disability one-half; duration one year.” Case. — Private IF. Oylesly, Co. H, 38th Georgia Regiment, aged 35 years, having been wounded at Fredericksburg, December 13th, was sent to Richmond, and admitted into Chimborazo (Confederate) Hospital on December 15th, 1862. A missile had entered the right breast between the first and second libs, passing entirely through the lung and lower portion of the Sect. II.] SHOT FRACTURES OF THE SCAPULA. 485 Fig. 222. — Gunshot fracture of the right scapula. Spec. 286, Sect. I, A. M. M. scapula. When admitted, the prognosis was unfavorable, the patient having lost a considerable amount of blood from the lungs, and bein. £d.StaucK. prnxt T Sinclair ft Son, Cliromo-lHh . PI . C lltirlcs Belts . ( See pa2C 'IBS.) PLATE X. PENETRATION OF ANTERIOR MEDIASTINUM BY CANISTER. Sect. II. ] SHOT PENETEATIONS OF THE STEENUM. 487 the level of the third rib, on the left side, and tore through the costal pleura. It remained in the wound and was removed by the patient. On the following day, Betts entered the hospital of the 2d division of the Sixth Corps. Through the wound,- the arch of the aorta was distinctly visible, and its pulsations could be counted. The left lung was collap.sed. Wlien sitting up there was but slight dys]inoca. Several fragments of the sternum wereiemoved, and the wound soon granulated kindly. On May 10th, a colored drawing of the wound was made. (No. 19, Surgical Series of Drawings, S. G. O.) On July ;'tli, the patient was transferred to Washington, convalescent. He ultimately recovered ])erfectly. This man was discharged the service on June 27th, 1863, and was subsequently pensioned, his disability being rated three-fourths and permanent. On April 5th, 1864, Pension Examiner L. A. Smith reports that the injured lung “still continues defective somewhat, causing dyspnoea.” The following is an extract from the patient’s letter, dated Newark, New Jersey, April 22, 1872, in reply to an inquiry regarding his condition : “My wound is not what you would call a running sore exactly, but still there is all the while a kind of dry scab forming and coming off one after the other, and it is very tender. I have spoken to several doctors about it, and they say that it will always be so on account of the bone being broken in such a waj' that it is ragged and does not heal solid. My health is as good as I ever ex]iect it to be again. My left lung is a very delicate thing, and the least cold seems to go right to it, and the weather we have here at this season of the year is very rough on me; but I suppose there is no use of crying over spilt milk, but must only try to make the best of a bad job.” Case. — Private P. H. B , Co. C, 147th Pennsylvania Volunteers, was wounded at Chancellorsville, 5Iaj' 2d, 1863, by a conoidal mu.sket-ball, which entered between the second and third ribs, on tin; right side, two indies from the median line, fractured the sternum, and lodged beneath it. The wound bled prxifusely, but the hannorrhage was arrested by pressure. The patient was conveyed to Douglas Hospital, Washington, on !May 8th, and died the following day. He had haemojitysis and the symptoms of traumatic pneumonia. The pathological specimen, contributed to the Army ISIedical Slusenm by Assistant Surgeon W. Thomson, U. S. A., is figured in the adjoining wood-cut (EiG. 226). Case. — Private H. B , 27th Michigan Volunteers, aged 21 years, was wounded at Spottsylvania, May 12th, 1864, by a fi-agment of shell, which contused the iqiper anterior portion of the chest without lesion of the integument. He was admitted to Fairfax Seminary Hospital on the 16th; there was a large tumor at the point of injury and exten- sive suggillation. Cold-water dressings were applied, and extra diet allowed. On the I'^A 'm'm a*‘‘‘clicd. 17th, the tumor was evacuated by an incision, leaving a cavity some two inches in diameter. The patient did extremely well under the administration of quinia in small doses, and an extra diet, until June ICth, when there was anorexia, dry tongue, an apparently healthy discharge from the wound, troublesome cough, and inuco-inirulent sputum. To combat these symptoms, tonics, stimulants, and an extra diet were directed. The patient sank gradually, and, by July 5th, complained of great pain in the lower part of the abdomen. There was also difficulty in micturition, which lasted five days. On the 10th there was difficulty in speak- ing; great dy.spncca; respiratory murmur around the wound, and pulse varying from 100 to 110. This was followed by coma, and the patient died on the 15th. The autopsy revealed a fracture of the sternum — small pieces of the manubrium being driven in — with two apertures in the bone communicating with the lung. There was a large abscess in the left lung, with evidences of extensive pleuritis and effusion in the ])leural cavities. The remaining organs exhibited nothing worthy of remark. The pathological specimen is carious within to a considerable extent, and, on the internal surface, is partly covered with a plate of new deposit. It was contributed to the Army Medical Museum by Assistant Surgeon TI. Allen, U. S. A., and is figured in the adjoining cut (FiG. 227). Case. — Private Edwin Steele, Co. A, 3d Missouri State ililitia Cavalry, aged 23 years, was wounded at Caledonia, Missouri, September 13th, 1864, by a round ball, which entered through upper part of sternum, passed backward, and lodged under the left scapula. He was treated at Caledonia until October 11th, when he was sent to the post hospital at Cape Girardeau. Discharged from service February 27th, 1865. Pension Examiner E. \V. Bartlett reports, Juno 22d, 1869, “the missile interferes with the motion of the arm and causes hajmorrhage of the lungs. Is unable to labor and not likely to improve.” He was still a pensioner in March, 1872. Case. — ^Private George W. Edkin, Co. D, 12th Michigan Volunteers, aged 27 years, received a gunshot penetrating wound of the chest, at Shiloh, April 7th, 1862. The missile entered through the centre of the sternum, jiassed through the mediastinum, and lodged beneath the posterior border of the left scapula. Fie was taken to the field hospital, where the wound was dressed with adhesive plaster. During the first twenty-four hours, the external haemorrhage was profuse, and air passed through the wound for three days. Three days after the reception of the injury, the ball was extracted by Surgeon E. C. Kedzie, 12th Michigan Volunteers. The internal haemoiThage was considerable and frothy, and bloody expectoration continued for some three weeks. Morphia was administered regularly, and the patient was kejjt upon a light diet ; stimulants were prohibited. During -three months the sputa were bloody, gradually lessening but not entirely ceasing for more than a year. He was removed to the Infirmary Hospital, Pittsburgh. The wound finally healed about the middle of July, 1862. He was discharged from service on November 7th, 1862. Pension Examiner Ira C. Backus rciports, December Ist, 1863, that “ there is permanent lameness of the left shoulder.” Dr. M. Gill, in a letter to this office, dated March 26th, 1866, says that “ the track of the ball is tender; constant pricking pain through the lungs ; dyspnoea increased by exercise. Severe coughing excited by fatigue or cold produces haemoptysis. Does not have constant cough. Cannot lie upon either side long .at once ; more difficult upon left, easiest upon the back, requires frequent change of position, but at all times needs to lie with his head elevated.” Fig. 2:37. — FpjuT pertiou of the stornuin fractnrcil longi- tudinally and ohliipiely, with displacement. 21)1 1. Sect. I, A. M. M. Fig. 22. 317). “ the result is almost inevitably fatal,” but enough cases are on record to prove that the double injury is not necessarily fatal either from haemorrhage or collapse of lungs and aspljysia. Hut in a somewhat extensive examination, I lind veiy few allusions to this form of injury. It is true that Sir Evkuard lIOilK has given ( Trans, of a Society for the Improvement of Med. and Chir. Knowledge, London, 1800, Vol. II, p. 171) an account of a case in which he traced, thirty- two years alter the injury had been received, the course of a ball from where it entered the left lung through the upper lobe of the right lung. Hut I believe Sir E. Horae's explorations enjoy little credit among his countrymen. DemmE (Miliidr-Chirurgische Studien, 'Wurzburg, 1804, p. 158) records 10:1 cases of gunshot wounds, with orifices of entry and emergence, of which eleven were examples of lesions of both lungs. Of the latter, nine proved fatal. MaCLEOD {op. cit. p. 240) observes : “ Of wounds penetrating both sides of the chest, I met with four examples only. In all these the wound was inflicted by grape, and all died in a short time.” Gant, F. J., Science and Practice of Surgery, London. 1871, p. 883), says: “ Wound of b.Rh lungs simultaneously is pr.iportionately more dangerous ; and principally owing to double pneumothorax, with collapse of the lung, inducing more complete asphyxia. Recovery is, however, an occasional termination, even in such cases.” Hut these dicta appear to be suggested by inference ratlier than (>bscr\'ation. L>r. Frazer {op. cit., p. 52) mentions a case of a gunshtd wCanii) Hospital, Ahnv York Harbor. On September loth, he was admitted to Officers’ Hospital, Annapolis, Maryland, and discharged from service on September '27th, 1804. A’ot a pensioner. The case is re])orted by C. N. Chamberlain, U. S. V. Ca.se. — Corporal Lucius G. Bradley, Co. B, 136th E^ew A’ork Volunteers, aged '29 years, was wotinded at Gettysburg, July 2d, 1863 ; the missile entered the right chest beneath the clavicle at its articulation with the sternum, and lodged between the spine .and scapula. The patient stated that the wound bled vcT-y freely at first, and, in a few minutes, he discovered that he could not breathe without, in the first place, closing the wound with his hand. The haemorrhage ceased when he lay upon his back. The surgeon of his regiment and the brigade surgeon pronounced his case hopeless. The wound was closed with metallic sutures and hermetic.ally sealed with collodion, by Surgeon John J. Milh.an, U. S. A., medical director of the Fifth Corps. Nourishing diet was administered and quiet enjoined. On July 24th, he was transferred to Chestnut Street Hos)utal, Harrisburg, Pennsylvania. When admitted, he was very weak, and had entirely lost his voice. The wound had never been interfered with after the first dressing was applied on the battle-field. On August 15th. the dressings became loose, and were removed, with the sutures ; the wound wgs found to be quite healed. He was discharged from service on August 18th, 1803. On one occasion during his stay at the Harrisburg Hospit.al, he ex])ectoriated a little bloody pus. Pension Examiner W. M. Herron rejiorts, on Felu'uary 16th, 1866, that the jtensioncr suffers from pain at the point where the b.all lodged. The case is repoi-ted by Acting Assistant Surgeon W. S. Woods. Bradley was in tolerably good health on March 4th, 1872, when he drew his half pension.* Ca.se. — Private John P. Frink, Co. F, 17th Maine, aged 19 ye.ars, was wounded at Deep Bottom, August 18, 1864, by a conoidal ball, which penetrated the left chest in the seventh intercostal space, one inch outside of a vertical line through the nipple, and emerged near the angle of the seventh rib. The wound was hermetically sealed at the hospital of the 3d division. Second Corps. On August 27th, he was transferred to Finley Hospital, and discharged on June 8, 1865. Pension Examiner E. F. Sanger rejiorts, October 27, 1868 : Necrosis followed, and spitting of blood. Dulness in region of wound and adhesion of lung to pleura. I’ain, soreness, and dj'spnosa upon exposure and hard work.” Keported by' Surgeon O. Evarts, 20th Indiana. Case. — Lieutenant Adolphus F. Vogelbach, Co. B, 27th Pennsylvania, received a penetrating shot wound of the chest at Mission Eidge, November 25, 1863 ; the ball entered betw'cen the seventh and eighth ribs, and passed through the middle lobe of the right lung. He was taken to the hospital of the 2d division. Eleventh Corps, and the wound was hermetically sealed with sutures and collodion, by Surgeon B. L. Hovey, 133th N’ew York. On December •22d, he was convalescent, and was trans- ferred to Officers’ Hospital, Lookout Mountain, whence he w'as furloughed February^ 3d, 1864. Having returned to duty, he was promoted to the rank of Captain, April '27, and mustered out with his company on June 10, 1864. Pension Examiner . I. Cummisky reported, June 17, 1864, that Vogelbach was much -weakened and unable to do the lightest kind of work. Pension Examiner Win. M. Cornell reported, October 26, 1865 : Wound more painful ; raises more blood, and has greater difficulty of respiration. May 8, 1873, Dr. Hovey wrote that in Lieutenant Vogelbach’s case the anterior wound healed kindly, the posterior did not.” He adds, “ Two soldiers reside in this city (Eochester) who were treated by me after this plan ; they are in good health.” The names ave not given. C.VSE. — Private Henry Herrick, Co. II, 5th IMichigan Volunteers, aged 20 y'ears, was wounded at Petersburg, Virginia, June 16th, 1864, by' a conoidal ball, which entered anteriorly between the second and third ribs, injured the apex of the right lung, and passed out behind the scapula. He was taken to the hospital of the Second Corps, wlicre the wound was hermetically sealed. On the 24th, ho was transferred to Mount Pleasant Hospital, Washington. On .Tanuary 4th, 186.5, he was sent to Hai-per Hospital, Detroit, Michigan, whence he was discharged from service on February 5th, 1865. A communication from the Commissioner of Pensions, dated April 8th, 1868, states that Herrick is a pensioner, his disability being rated one-half and pei-manent. The case is reported by Surgeon O. Evarts, 20th Indiana Volunteers. Case. — Private Horace B. Walters, Co. D, 84th Indiana Volunteers, aged 21 y’ears, was wounded at Kenes.aw, Georgia, June 27th, 1864, by’ a conoidal b.all, which penetr.ated the left side of the thorax. Ho was taken to the hospital of the 1st division. Fourth Corps, where the wound was hermetically sealed by Assistant Surgeon William H. Matchett, 4()th Ghi'o Volun- teers. On .Inly 3d, he was transferred to Hospit.al No. ‘2, Chattanooga; on .July23d,to Hospital No. 8,Nashvillo; on Septemlau' 9th, to .Jefferson Hospital, Indiana, and, on December 12th, to Cumberland Hospital, Nashville, whence he was returned to duty on December 20th, 1864. He is not a pensioner. The case is reported by Surgeon .1. D. Brumley, IT. S. V. Ca.se. — Lieutenant I’ercival Knowle.s, Co. K, 6th Maim; Volunteers, aged ‘23 years, was wounded at Eai)pS. V., medicid director of the Eighteenth Corps. Skct. II.] TREATMENT r,Y HERMETICALLY SEALING. 50o Case. — Rrivate Miles Fincli, Co. L, Sd reiins 3 Tvaiiia Cavaliy, aged 3G years, was wounded at Toles of MUitary Surgery, lid ed., 1829, p. 378) that; “This immediate clcsure of the wound has been recently adoi>tcd by Larre^’- with success. The practice is not novel. John de Vif^o, in the tenth chapter of his third book, has given an account of it ; and I’are says that the practice is founded on reason and truth, if there is little or no blood poured forth into the cavity of the chest ; he, however, does not close the wound fur the first two or three days, to prevent accumulation of blood. La Motte closed all wounds of the chest most accurately with a tent ; hence, perhaps, it is, that, in the whole course of his work, he scarcely moniions emphysema. Ills history of the secret dressing, which consisted in sucking out the blood, and then closing the wound, is highly worthy of notice, and is given witli great fidelity in his Traill Complet de Chirurgie, Vol. Ill, p. 20, I’aris edition, 1732. But Bclloste seems to have done more practical goed in this way than any other French surgeon. lie argues strenuously and successfully against keeping the injuries of the chest open, in his Chirxirgicn d'Uopital, and he sets a very valuable example to writers if a more modern date; for, in a letter in e.vplanation of Sancassani’s Italian translation of his work, he acknowdedges his obligations to honest old Magatus, who wrote nearly one hundred years before him. [D. J. Larrey treats of the subject in his Memoircs de Chirurgie Militaire ct Campagnes, T. II, p. 154, in speaking of incised wounds of the chest observed in the campaign in Egypt. Pare {Qiluvres Comjdetcs, T. II, p. 94, Livre 8, Chap. XXXll) has, as Malgaigne remarks, borrowed from Vigo. (The edition in the Surgeon General's Library is the Munich edition of 1521, Practica in chirurgia cojnosa, small folio.) The allusion to healing wounds of the chest by first intention is in the first part of the third book, fol. LXXIV. Vigo in his turn copied from Guy de Chauliac (La Grande Chirurgie, composec 1‘an de grace, 1353). See Joubert’s restoration, published at Toumon in 1(119, Chap. V, p. 290. The admonition which Dr. Howard has unheeded is funiished by Belloste in his eighth chapter. Cesari Magati, professor at I’^errara, published his work "De rara Medicatione Vidnernm, Folio, apud Venetiis, in KilO: Unionem labiorum, mitem medical icnem, clausum vidtius commoidat.''' — (Crcutzenfeld.) Pai6 condemns the application of stitches in penetrating wounds of the chest, in the thirty-second chapter of h.s eighth book, and also in the Playes d’kacquebufes, 1.552, fol. 76. Felix WiuTz, in 157(), advanced the treatment of penetrating wounds of the chest by sewing them up as a general method. (Practica der Wundarzney. darinn allerlc.y schddliche Misshrduche der Wunddrzte abgeschajft werden. Aus den llandschriften des Autors, vou neuen ubersehen und vermehiet diu'ch Budolph Wurtzen, Basil, 1576) ; Professor 'W Longmore remarlvs that “ ‘ hermetically scaling’ is only a new term but even tliis admission is erroneous ; for in 1827, Graefe, of Berlin, in the case of a man of thirty-two, who had stabbed himself between the fifth and sixth ribs, near the sternum, the knife iienetrating two inches, blood and air escaping freely fr; m the woiiurotrusion of the lung after a gunshot wound.” At Waterloo, Samuel Cooper ” had a patient with a protrusion of a piece of lung, four or five inches in length. The part was much bruised and could not be easily reduced. I therefore applied a ligature around its base and cut it off. Previously, however, I made an incision in it to ascertainMviiother it would bleed freely, which, being the case, induced mo to use a ligature. I was afterward informed by my friend Mr. Collier that the man died. ” Dkmme (MilHiir-Chirugische SLudicn, Wurzburg, 1864, B. II, S. 152) claims to Jiave seen four cases in the North-Italiau military hospitals in 1859. Med ft J-ury Hist, of the M'av of the Kc'l)elli()ii. I'iirl I.Vol II. 0p.pa9 'T Sinclair 8* Soil. Chroiiio-lHh . Sect. II.] HERNIA OF THE LUNG. 615 Division Hospital. On Deccnilier lie was transferred to Camp Parole Hospital, wlieiiee lie was discliarped fiom service February Ctli, 18C5. Pension Examiner 13. 8. Slid man report.s, .Inne 2:’d, 18G5, tliat tlic ball earrieil away a jiortion of the eighth and ninth libs, left side, forwaid of their angles, resulting in hernia nearly the size of a' small tea-cup, which it is difficult to keep in place with bandage and compress. Disability total and more or less permanent. He was still a pensioner in March, 1872. This would appear to have been an example of consecutive pneumocele, the lung- forcing the soft parts outward as their support was withdrawn hy the removal of splinters and exfoliations from the fractured ribs. The report of the regimental surgeon, Dr. J. N. Freeman, and the records of the Sixth Corps hospitals, and of the General Hospital Ho. 21, at Richmond, and of the transport steamer Hew York, have been vainly searched for additional information. The next is a very extraordinary case. The appearance of the protruded lung shortly after the accident, and of the tumor after cicatrization was complete, are illustrated by two plates (Plate XI opposite, and Plate XII, opposite page 516). Case. — Captain Robert S , Co. A, 29th New York Volunteers, was wounded at Chancellorsville on May 2d, 18()3. A round musket ball, fired from a distance of about one hundred and fifty yard.s, entered the eighth intercostal space of the left side, at a point nine and one-half inches to the left of the extremity of the ensiform cartilage, and fractured the ninth i-ib. W-ithout wounding the lung apparently, the ball passed through the diaphragm, and entered some portion of the alimentary canal. Captain S. walked a mile and a half to the rear, and entered a field hospital. On examining his wound, the surgeons found a protrusion of the lung of the size of a small orange, which they unavailingly attempted to reduce. The wound was enlarged, and still it was impracticable to replace the protruded lung. On May 3d, the field hospital, where Captain S. lay, was exposed to the enemy’s fire. He walked half a mile further to the real’, and was there placed in an ambulance, and taken across the Rappahannock, at United States Ford, to one of the base hospitals. Here fruitless efforts were again made to reduce the hernial tumor, after which a ligature was thrown around its base and tightened. A day or two subsequently, tlie patient jiassod into the hospital of the 2d division of the Eleventh Corps, into the hands of Surgeon Robert Tliomain, 29th New York Volunteers, who removed the ligature from the base of the tumor. A small portion of gangrenous lung separated and left a clean granulating surface beneath. On May 7th, the ball was voided at stool. On May 8th, the patient was visited by Surgeon John H. Brinton, U. S. V., who found him walking about the ward, smoking a cigar. There was an entire absence of general constitutional symptoms ; no cough, no dyspnoea, no abdominal pain ; the bowels were regular and appetite good. The protruding portion of the lung was carnified ; there was a dulness on percussion, and absence of the respiratory murmur in a zone an inch and a half in width around the circumference of the base of the tumor. Surgeon Tliomain stated that the hernia had been gradually diminishing in volume. It was, at this date, half the size of an egg, and covered with florid gi’anulations. On May 10th, a drawing of the parts was executed by Mr. Stanch, artist of the Army Medical Museuih. (See Chromolithograph No. XI.) On June 2d, Captain S. was transferred to Washington. There was an elastic, partly reducible tumor, over which was an oval granulating surface an inch and a half by three-fourths of an inch. Thu vesicular murmur was perfect throughout the lung, except in the immediate vicinity of the tumor. Compression of the tumor was advised. After a furlough of sixty days. Captain S. was again examined. The wound had entirely healed ; the resjiiratory sounds were normal ; there was still a slight hernia of the lung. The general health of the patient was excellent. At this date a second drawing was executed. (See Chromolithograph No. XII.) Tlie captain w’as discharged from service on June 20th, 1863, and was subsequently pensioned. On May 19th, 1864, Pension Examiner E. Swift I’cports the patient to bo entirely incapacitated from the wound, which, at that date, was considerably tumefied. He rates his disability total and temporary. September 19th, 1865: The tumor is reported to be undiminishod in size and painless. The patient can take ordinary, leisurely exercise, but is unable to run up and down stairs. He has no cough, but sufi'ers somewhat from gastric sjunptoms, his stomach being easily disturbed. The extra-thoracic tumor is resonant on percussion. The air, in entei-ing, produces a crepitant crack- ling sound; the expiratory murmur is feeble. March 14tli, 1867 : Two months ago, the tumor suddenly enlarged after straining efforts at lifting, being now five inches in its long and four and a half inches in its transverse diameter. The respiratory sounds are feeble. There is often nausea after eating, and great pain, referred to the tumor. Pressure over the tumoi' causes a gurgling sound, simulating the presence of air within the tumor, and borborygamus throughout the intestines. The patient declares his inability to eat meat. The contents of the tumor are not reducible ; tr.action on it and its contents produce nausea. A portion of the stomach has undoubtedly escaped through the diaphragm, and through the opening in the thoracic walls. A bandage, so arranged as to retain the tumor within its present limits, and ))revent further enlargement, was applied. A letter I'rom the patient, dated January 23d, 1870, leads us to infer that this bandage has fulfilled its indication. On January 31st, 1870, the patient was reported to have, in addition to his other troubles, a hernia of the stomach, which viscus p.assed uj) through the diaphragm and thence through the opening in the rib, so that the tumor on the left side contained both lung and stomach. He wore a compressing bandage. On July 20th, 1872, Dr. Win. 11. Romig, of Allentown, Pennsylvania, the family jihysician of Ca[)tain Stolpe, writes: “The hernial tumor is of a doughy consistence, its surface smooth, measures in its longest diameter four and a half inches. Stolpe says, it appears smaller at times; it cannot be reduced by taxis, neither can any communication ho discovered with the internal organs. Never gives pain, but dyspnoea is ])roduced upon hastening his ]iace or heavy lifting ; cannot lie on his left side for same reason ; cannot expand his lung fully, that is, beyond normal use. His stomach will take food often, but not much at a time; the left side of his body does not appear so strong us the right. Weighs about one hundred and sixty iiounds, and enjoys good health.” 516 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, In the next case nothing can he learned relative to the isochronism in the variations of volume of the tumor with the two acts of rcs})iration ; Case. — Private George W. Bowiiian, Co. K, 4tli Now York Heavy Artilleiy, aged 17 years, was wounded at Spottsyl- vaiiia, May lOtli, 1S64, by a conoidal ball, wbicb entered four inches below' the left axilla, and emerged two inclies to the left of the spinal column, on the same level. He was admitted to Armory Square Hospital, May ll'Jd, 1864. Hernia of a portion of the viscera occurred from ))oint of entrance and was ligated by Acting Assistant Surgeon D. W. C. Van Slyck. He was furloughed .July 1st, readmitted August 20th, again furloughed November 23d, and readmitted January 28tb, 1865. On February 2d, 1865, he was returned to duty, and mustered out September 26th, 1865. Pension Examiner W. C. Wade, Holly, Michigan, reports, November 12th, 1869 ; “ Gunshot wound through ninth rib below left scapula, ball emerging near spine, having penetrated the abdominal cavity. Pieces of bone have been removed, and part of the omentum sloughed away; the muscles of the side are weakened. Disability three-fourths.” The next is the only case of the series in which it is expressly stated that the lung was wounded. The integrity of the displaced portion of the lung had been regarded as an almost constant condition in traumatic pneumocele, the cases recorded by Roscius and Angelo being the only exceptions. In this case, it is possible that the edge of the lobe, the part usually protruding, was uninjured, the missile perforating the deep pulmonary tissue: Case. — Private James Infant, Co. G, 5th New Hampshire Volunteers, aged 19 years, was wounded at Petersburg, Ajiril 2d, 1835, by a conoidal musket ball, which entered just below the left nipple and emerged to the left of the si.xth dorsal vertebra, penetrating the left lung. He was admitted to the field hospital of the 2d division. Ninth Corps, and thence transferred by rail to the Second Corps Hospital, at City Point, sent thence by hosjiital steamer to Washington, and admitfed to Armory Square Hospital on April 16th. A portion of the lung, two bj' five inches, protruded through the wound of entrance. Death occurred from asjdiyxia on April 18th, 1865. The case is reported by Surgeon D. W. Bliss, U. S. V. The next very interesting case affords an example of herniti of the liver, omentum, and lung, complications which have received little notice, probably because of the rarity of recovery from such lesions. It recalls the case recorded by Sir Thomas Bell, in Duncan’s Commentaries (Vol. II, p. 319, 1785), of a grenadier of the 35th British Infantry, whom he saw at the military hospital at Point Levi, at the surrender of Quebec to General W olfe : Case. — Private B. S. Sheridan, Co. A, 9th Massachusetts Volunteers, was wounded at Malvern Hill, July 1st, 1862, by a musket ball, which entered the right side between the ninth and tenth ribs, and passed out a little to the right of the xyphoid cartilage. Soon after the reception of the injury, a portion of the lung protruded from the anterior wound, and from the posterior wound there was a constant dripping of bite. On .July 4th, Sheridan walked from the ambulance station to James River, a distance of a mile and a half, with the ho)>e of getting on hoard of a gunboat. He was disappointed, and was taken prisoner and conveyed to Richmond. No dressings were apj)lied to the hernia of the lung. It was uncovered, and the patient occasion- ally washeil it. He suffered little pain or dyspnoea, and there was an amazing absence of shock or prosti'ation. On July 25th, the bile had ceased to dribble from the jiosterior wound, and the hernia of the lung had greatly receded. He was exchanged, and on July 29th admitted into the hosjtital at Chester, and placed under a tonic treatment. The mass of flesh was found to be muscular tissue, and was itrotruding to the length of two inches, and was about the thickness of the middle finger. He soon complained of severe p;iin in the region of the diaphragm, which was augmented by taking a full breath, and of paroxysms of coughing attended with but slight expectoration. The cough and pain in the region of the diaphragm gradually disappetired under treatment. After the protrusion had been sloughed away, the wound closed, leaving a tumor beneath the skin, in the ))o.sition of what was the base of the protrusion. This tumor was slightly variable in size, but could not bo reduced. About tbe middle of September, a movable substance was discovered, which appeared to be a portion of ball flattened on the eleventh rib, by the side of the tumor ; it was determined to remove this substance, and at the same time ascertain the character of the tumor. On doing this, it was found to be an irreducible hernia of the omentum ; no bad symptoms followed the operation. It appears that the ball, after striking the chest, turned downward, ])assed through the oblique muscles, carrying with it a portion of their tissue, and was then deflected upward to the point of exit. The peritoneum was probably wounded near the point of exit, which allowed the omentum to follow in the track of the ball, and during the time required to slough away the pendant mass, it became agglutinated in its new position, which rendered it irreducible. The patient, at liis own reejnest, was returned to duty on October 31st, 1862. Pension Examiner J. W. Foye reports, under date of Aju-il 6th, 1869, that the '‘ball entered the right chest on its posterior aspect at a point corresponding with the angles of the ribs and through the last intercostal space ; passing forward it fractured the twelfth rib near its costal attachment, and escaped anteriorly four inches from the median line of the body, having first entered the abdominal cavity by detaching the diaphragm, to a small extent, from the ensiforin cartilage. Through the opening thus made, a process of omentum h.as floated upward constituting a form of costo-phrenic hernia. The injury is grave but not equivalent to the loss of a hand.” Under date of March 4th, 1872, the Pension Examining Board at Boston, Massachusetts, state : “There is now a hernia of the lung two inches in diameter at base at situ of wound of exit. The inferior half of the lower lobe of the right lung has undergone partial consolidation from interstitial deposit, submucous cre])ita- tion, dulness on percussion, and also i)liysical signs in hernial tumor. His general health is mucli impaireil, and he is at present incapable of any manual lat)or. His disability has increased.” Med.R '''urg. of tlie War of tlie Hebellion, I' ai l T. Vol II Op. page 5If). KJ St .'itK'li |>juy* 'I* Suirl.ur H- Sou, Cliroiiio-rilli PLATE XII. GUNSHOT WOUND OF THORAX AND ABDOM EN . Skct. 11.] HERNIA OF THE LUNG. 517 The sixth case is cited liy Dr. B. Howard in his report already ])rint,cd (p. 513), l)ub in such vague terms that it is impossible to identify the patient, or to determine whether the tumor was ligated or excised or reduced without operation : Case. — A soldier of the Eighteenth Corps I’eceived a gunshot wound of the chest, before the entrenchments at Petersburg, late in June or early in July, 1864. He was conveyed to the base hosj)ital at Broadwaj" Landing, in charge of Surgeon 11. B. Fowler, 12th New Hampshire Volunteers. He was placed in an hospital tent with a patient, Private Williams, who was under the charge of Assistant Surgeon B. Howard, U. S. A., who took notes of this and some of the other cases of chest wounds in the w.ard. The only facts reported in regard to this are as follows : “Tliere was extensive pulmonary hernia, which 1 had fixed so as to secure a permanent plug, with adhesions around the orifice, and also exhausted the pleural cavity of air. This, 1 suppose, is the case Assistant Surgeon Derby reports, in which the trochar was used without, as he had ‘learned,’ the removal of any fluid.” The seventh case is also wanting in essential details. It is published by Dr. F. II. Flamilton [op. cit., p. 295). It is interesting as one of the few examples of traumatic pneurnocele through a small orifice, and complicated by strangulation : Case. — A young soldier of the Fourth Corps, name not ascertained, was wounded at the engagement at Fair Oaks, May 31st, 1862. “Our attention,” says Dr. Hamilton, “was called to him the night after the second battle by one of the surgeons. He had been wounded by a ball on the left side of the thorax, a little below the nipple. The ball had not been found. He was l^dng upon the ground in a condition of considerable prostration. The hernia was about one inch in diameter, having escaped from an aperture which was very much smaller. It was completely strangulated, being quite black, and insensible to the touch. We applied to the neck of the hernia a strong silk ligature, for the purpose of expediting its destruction, and then made fast the ends of the ligature to the outer surface of the chest by adhesive plasters, to prevent the escape of the ligature within the cavity, in case the hernia should retire after it had sloughed. We saw this poor fellow the next morning lying in the same place. He had taken a little nourishment, such as we had to give him, and expressed himself as being comfortable, although he had lain without shelter two nights, and during each night he had been drenched witU rain. In this respect he suflered, however, only in common with at least two thousand other wounded and dying men. We cannot omit this additional tribute to the bravery of these noble fellows. During all this time, and we were with them every moment both night and day, there was never heal'd one cry of impatience or one murmur of complaint beyond that which was extorted by the agony of suifering. When the wounded were sent to White House, this boy was sent with them, and we have never seen or heard from him since.” Three of the seven cases, ^ in all probability, terminated fatally. Three of the four survivors wear retentive bandages with concave pads. One has ventral hernia, and two diaphragmatic hernia, the latter verifying Guthrie’s prediction [op. cit. p. 506) that wounds of the diaphragm will never be found to heal, but will remain open for the transmission and possible incarceration of the abdominal viscera into the chest. The probability of the incarceration and possibility of strangulation, and consequent necessity for the operoTion described by Guthrie, has doubtless been explained to these pensioners, with warnings to avoid muscular exertions and stooping postures. In two of the successful and one of the fatal cases, ligations were placed about the base of the pulmonary protrusions. In none of the cases was the wound enlarged or the intercostal space wedged open to facilitate the reduction of the hernia. A more particular account of the means adopted in the sixth case, in order to occlude the wound with the lung as a plug, and to exhaust the pleural cavity of air, would be interesting. J. CloqueF explains the mechanism of protrusions of the lung through a wound as follows : The expiratory muscles contracting simultaneously and suddeidy on the reception of a blow, and the glottis closing, the air, unable to escape by the trachea, fills the pulmonary cells, and the elasticity of the air forces the lung against the thoracic parietes and a portion tends to escape at the weakest point. NdlatoiF accepts this explanation, but Malgaigne^ proposes a different hypothesis, believing that in a sudden forcil)lG * Cloquet, Nouveau Journal dc MHecine, 1819, T. VI, p. 328. * ^XliLATON, Pathologie Chirurgicale, T. Ill, p. 411. ^MalOAIGNE, Traite d' anatomic chirurgicale, 1859, T. IF, p. 209. ■•There was au eighth case, inadvertently omitted here, complicated with a fatal abdominal wound, it is detailed as CASE 474, on page 135 of the Second Surgical Volume. 518 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, expiration with the glottis partially closed the air in the sound lung will pass into the bronchi of the injured side, forcing the lung outward if there is a wound in the parietes. Chelins^ and M. Morel-Lavallde' accept neither of these explanations. The latter has written an exhaustive memoir on the subject, which may be studied with great profit, lie has collected nearly all the recorded instances prior to the publication of his paper. They number but thirty,^ and only three of these, reported by Richerand, Cloquet, and S. Cooper, resulted from gunshot wounds. If Guthrie’s three cases, of which the particulars are wanting, occurred after gunshot,^ and the four cases referred to by Demme, be added, and Baudens’s case in Algiers, and the seven examples cited in this subsection, the number of recorded instances of pneumocele after gunshot injury still remains less than a score.® Fischer, in his recent admirable work on the surgical experiences of the Franco-German war, observes that he could learn of no example of this accident among the wounds of the chest observed in the Saxon and Prussian armies. There are but two affections with which hernia of the lung is liable to be confounded, viz: intercostal epiplocele, with which it may also be complicated, as in two of the cases here reported, and a pulmonary abscess or vomica approaching the surface. Careful inspection with auscultation and percussion should serve to establish the differential diagnosis ; but mistakes have been committed, as in Ptuysch’s case. There is on record but a single instance of successful reduction of a traumatic pneumo- cele without previous ligation, the case of Angelo.® A good recovery ensued, though the lung tissue was wounded. Authors generally advise gentle taxis, and some recommend the enlargement of the wound to return the tumor ; but there is no evidence of the expediency of this measure. Excision or ligation were employed in most of the cases, and no bad * CHELIUS, A SysUm of ‘Surgery^ American reprint of SontlFs translation, Yol. I, p. 497. ^Morel-LavalleE, Jlernics du poumon (Mem. de la Soc. de Cliir., 1847, T. I, p. 75). 3 IlOLANDUS, of Parma {Chirurgia, T. Ill, Cap. 25, Venet. 1449), was the first author to report a case of traumatic pneumocele. The tumor was excised, the pedicle left in the wound, and the patient recovered. IIOSCIUS next ohscn’cd a case, in IGOG, remarkable as following a sword-thrust between the fifth and sixth ribs, deeply wounding the lung ; excision ; recovery (Fabricius Ilildanus, Opera, Obs. 22, p. 107). G. liOl'SEAU {Observa- tions mcdicinales et cliirurgicales, }>. 25, Bordeaux, 1G17) relates an example, the result of a pike-stab between the third and fourth ribs — reduction after excision. IlHODiUS, of Padua {Ohservationum mcdicinalium, Centurits III, 8 vo., Padoue, 1G57), cites a case caused by a large sword wound in the side, with recovery after excision. A canula was left in the orifice. When this was discontinued the wound closed. NICHOLAS TULriL’S, of Amsterdam {Ohservat. Mcdiccc^ T. Ill, p. 124, 3 cd. 1G72), describi’d a large hernia of the lung weighing three ounces, which he ligated and excised five days after the patient had been stabbed in the chest. The protrusion did not appear till the third day after the wound was inflicted. RUYSCH {Ohs. anatomico-chirurgicarum Cent., Obs. 53, p. 70, Amstelodami, 1691) records a traumatic pneumocele mistaken for an epiplocele and successfully ligated. BELL, of Cork, describes (Duncan’s Medical Commentaries, 1785, Vol. II, p. 349) a large pulmonary hernia protruded through a stab in the right side, between the ninth and tenth ribs. Strangulation ensued and gangrene ; but the patient ultimately recovered. Sabatier {Medicine Operatoire, T. I. p. 20G, 2d cd., 1810) mentions a ease fullo^ving a bayonet thrust. Consult also on this subject: BOYER, Traite des maladies chirurgicales, 5™® 6d., T. V., p. 619; HenXEX, Principles of Military Surgery, 3d ed. p. 376; GODIL, Du mecanisme de la respiration; quelques mots sur les de. poitrine, les causes de Vemphyseme et sur celles des qmeumoceles, These de Paris, 1858, No. 10 ; Jarjavay, De Vinjluence des efforts dans les maladies chirurgicales, Paris, 1847; llICHET, A., Traite pratique d'anatomie medico-chirurgicale, Paris, 1857; Vergne, Ilernie du poumon, These de Paris, 106; Grateloup, Journal de Vandermonde, T. 53, p. 41G; TllYLLAYE, Traite des, bandages et appareils, 3“® 4d., Paris. 1815; IxiCllERAND, Nosographie et Therapeutique chirurgicales, T. Ill, p. 300 ; IllCHTER, Chirurgisch Dibliotcl-, B. Ill, S. 138; Mercier, Journal general de Medicenc, T. 34, p. 378 ; BOERIIAAVE, in De Haex, Institutiones qmthologicse, T. I, Par. 712, p. 333 ; PLATER, Observationes, p. 9G; BERTHE, Journal de Sedillot, T. XVII, p. 61 ; Larrey, H.-, DuUetin de la SocieU de Chirurgie, T. VI, p. 521 ; and CASPAR'S \Vochenschrift for case of Scharf, 1845, No. 9 ; Baudens, Clinique des plaies d'armes a feu, Paris, 1836, p. 247 ; VELPEAU, Comptes Rendus de I'Acad. dcs Sci., 1844 ; IIUGUIER, Mem. de la Soc. de Chir., T. I, p. 194 ; Fischer, II., Kriegschirugische Erfahrungen, Th. I, S. 124, Erlangen, 1872 ; LARREY, D. J-, Mem. de Chir. Mil., T. Ill, p. 91. have searched in vain through Guthrie's work on gunshot wounds, his monographs and lectures, for some additional information to that in the Commentaries regarding tlie three cases of pneumocele he saw at Brussels. Thomson alludes to one of them in his Observations after Waterloo, p. 92, ®No allusion has been made to the Congenital and Spontaneous varieties of hernia of the lung, on which CruveilhIER {Anat. Path., Liv. XXT, p. 1), Cloquet {Nouv. Jour, de Med.. T. VI, p. 309), and H. 11. SMITH {Principles and Practice of Surgery, 1863, Vol. I, p. 499) have treated, as these are foreign to the present subject. Professor Smith has oliserved two cases of spontaneous pneumocele, remarkable for their bulk and facility of reduction. He states very positively that their volume enlarged on inspiration. A very interesting case of hernia of the lung, following an incised wound of the left chest, is reported by Dr. T. B. Hale, of JMinersville, Pennsylvania, in the Philadelphia Medical Examiner, February, 1855, p. 7.5. A segment of lung, six by two and a half inches, was removed. There was neither cough nor dyspnoea. A rapid recovery ensued. The specimen is preserved. The protrusion is alleged to have expanded during inspiration. Th« same allegation is made in regard to the behavior of a protrusion of the lung in a case of wound of the liver and diaphragm, which will be reported farther on. We must believe that these statements of the augmentation of the tumor being synchronous with inspiration were all founded on faults of memory or errors of observation. Indeed in Dr. Hale’s case the protrusion only appeared in coughing. ‘’Angelo, Gazetta medica di Milano, February, 1844. Sect. II.] HEMORRHAGE. 519 results appear to have followed these operations. Non-intervention is probably the safer precept. After a while the protrusion contracts adhesions with the walls of the thorax and occludes the opening.^ Hemorrhage. — Notwithstanding the remarkable manner in which the large vessels often escape injury from missiles entering or traversing the thorax, eluding them by resiliency or sometimes deflecting them in their passage, bleeding is the most common and the most fatal of the complications of gunshot wounds of the chest. It may arise from lesions of the larger arteries supplying the parietes,^ from wounds of the primary carotids and subclavian; of the venous and arterial brachio-cephalic trunks; of the aorta and superior vena cava and azygos vein; of the pulmonary vessels; of the internal mammary and intercostal artery; and also from laceration of the pulmonary parenchyma and from wounds of the heart. Many of these injuries are either instantaneously mortal, or the partial or temporary recoveries are regarded as surgical curiosities. Those that are in some degree amenable to treatment are therefore invested with the greater interest, and demand all the surgeon’s solicitude and skill. The experience acquired in the late war has added to our knowledge of some of the rarer forms of these lesions, and served to indicate and corroborate what apparently are the sounder of the conflicting views as to their treatment. Wounds of the Aorta and Cavas. — No instance has been found upon the returns of a wound of the -arch or thoracic portion of the aorta if any such cases occurred, the patients did not survive long enough to receive hospital treatment. This curious exemption from injury cannot depend exclusively upon the resiliency of the arterial coats, for the Army ]\Iedical Museum contains two specimens^ of gunshot injuries of the abdominal aorta, in one of which the trunk is fairly perforated by a pistol ball. Since the war. Acting Assistant Surgeon W. J. Piper,’’ has reported an accidental pistol-ball perforation of the arch of the aorta. The wounded soldier lived long enough to be carried across the parade to the post hospital at Baton Rouge. The specimen was not received at the Museum. Surgeon J. A. Lidell,'* * U. S. V., has recorded a case in which he made an autopsy upon a man shot by a pistol ball, which entered at the junction of the cartilage of the third rib and the sternum, grazed the left lung, and perforated the aorta just without the semilunar valves. The pericardium was filled with coagulated blood, and there was copious extravasation in the pleural cavities. The course of the ball was altered somewhat by grazing the lung. It was deflected slightly to the right. Death was instantaneous. Dr. J. B. White’ mentions a case of bayonet stab causing a small puncture in the aorta a few lines without tlie pericardium. The profuse hsemorrhage was promptly fatal. ^Surgeon A. B. Crosby, U. S. V., records to Part I, p. 11) a serious case of intennediary lia'inorrhagc (tenth day) from a gunshot wound involving the external mammary {ihoracica longa). Acting Assistant Surgeon II. M. Dean gives a fatal ease of secondary haemorrhage from the left subscapiilar. The specimen, presen-ed as a wet preparation, is numbered 1.635 of the Surgical Section. The artery sloughed twentj'-tive days after the pas.-^age of a musket ball through the axilla, l^rivate F. M. D , Co. D, 35th North Carolina llcgimcnt, aged 27 years. Wounded at I^ctcrsburg, June Ifith, 18G4. Bleeding arrested by pressure and I^Ionscl’s salt, July 10th; fatal rccun-ent ha-morrhage on July 12th, IStM. Examples of ligations of the long thoracic and of branches of the circumflex arteries are given in Section III of this Chapter. *It is well known that the annals of surgery contain a few such examples. Guattani {Auctorum I.atinorum de Ancurismatihns CoUcefio, Boma, 1745) records the case of a man who survivi’d for eight years an incised wound of the arch. Pkllictax describes {Clinique Chi rurgicalc, Paris, 1810, T. Ill, p. 211) the case of a man who lived two months after a puncture of the aorta near its origin by a foil. IliciL (Henke's ZdUchrift^ 1837, B. 11, S. 459) details a ease in which a patient lived twelve months after receiving a stab in the ascending aorta. Gkken, T. Itl., of Macon, Georgia, juiblishes (jSo?d/Q TT * * , 1 ..*• descending; cava. The patient survived long enough to be Fig. 239. — Heart, great vessels, and portion O i o o ■55(i7?SectnWMlTL Carried from his post to the hospital close at hand. In the same report (p. 146) Assistant Surgeon S. M. Horton, U. 8. A., relates the case of a soldier of the Eighteenth Infantry, with an arrow wound of the descending vena cava. Tlie steel point of the weapon, entering at the junction of the sternum and the first right rib, penetrated three inches downward and inward, cutting the margin of the upper lobe of the right lung and inflicting a wound an eighth of an inch in length in the superior cava, just without the pericardial sac. Althouglp scalped and suffering from other wounds, the unfortunate man survived over forty hours. Large masses of coagula were found in the thoracic cavity. Wounds of the Innominata. — Two examples of gunshot injury of this trunk may be inserted here, and another, of a conoidal musket liall embedded between the innominata and the descending cava within the pericardium, will be recorded with wounds of that membrane : Case. — Private Frederick Smith, Co. A. 134tli New York Volunteers, aged 20 3 ’ears, was wounded at the battle of Gettysburg, I’ennsylvauia, July 1st, 1833, by a i-ifle ball, which entered above the right clavicle, passed under the sternum, and emerged between the fourth and fifth ribs. He was treated at the Eleventh Coiqrs Hospital, at Gettysbui'g. On July 22d, hanuorrhage took place from the arteria innominata, for which compression was applied. Death followed on July 25th, 1863. The case is reported by Surgeon James A. Armstrong, 75th Pennsylvania Volunteers. Case. — Private W^illiam A. J , Co. E, 7th West Virginia Volunteers, aged 26 years, was wounded in the engage- ment on the Weldon Railroad, October 27th, 1864, by a conoidal musket ball, which entered at the right upper angle of the sternum, passed under the clavicle, and lodged in the thorax. The wound was plugged with lint, and the wounded man was conveyed to City Point, and thence, on an hospital steamer, to Washington, where he was received at Emory Hospital. On October 30th, he was kejit quiet, with a simple dressing to the wound. . On the 31st, he was placed under the influence of chhu'ofonn, and.an exploration was made for the ball, which led to a profuse haemori'hage. Plugging the wound was the only * Circular No. 3, S. G. O., IriTl, A Report on Surpical Cases, etc., p. 34. Sect. II.] WOUNDS OF THE GKEAT BLOOD-VESSELS. 521 alternative. Afterwai-ds a compress and bandages were applied. On November 1st, the patient suffered greatly from dyspmra caused by liEEmotborax. The blood effused in the mediastinum appeared to compress the trachea, lie died on November 2d, 1864, five days after the reception of the wound. The autopsy was made by Surgeon N. IL Moseley, U. S. Y., in charge of the hospital. The ball was found resting against the innominata, having ruptured its coats and produced a diffused aneurism. The opening in the innominata is oval, nearly half an inch long, and is situated on the front part of the vessel, a little way below the bifurcation into carotid and subclavian. The specimen was contributed to tbe Army Medical Museum b}^ Surgeon Bloseley, and is No. 3410 of the Surgical series. The clinical notes were furnished by the ward surgeon. Dr. C. B. I»IcQuesten. Wounds of the Subclavian Artery and Vein. — Wounds of these great blood-vessels occasionally come under the surgeon’s treatment. It is quite time that the dictum of Jourdan’’' that surgery is powerless in lesions of arteries within the cranial, thoracic, and abdominal cavities should he expunged from the text-books. At least five cases occurred during the late war, of wounds of the subclavian in which surgical intervention was justifiable, and in one of these, the left subclavian was successfully tied by a Confederate surgeon, for a wound of the vessel where it passes across the first rib. Though such lesions are immediately mortal in the majority of cases, there are instances in which the bleeding is delayed or arrested, the laceration of the artery being obstructed by a spicula of bone, or by the missile or a fragment of clothing or other foreign substance. In such cases, audacity is the part of prudence; Case — P rivate Jolm J. T- -, Co. A, 122(1 New York Volunteers, was admitted to tbe field bospital of tbe Sixth Corps, Sej)tember 20th, 1864, with a gunshot wound of the right side of the neck, received the day previous at Winchester, Virginia. Wdieu admitted, he was very ^veak from haemorrhage from wound and hacmopt 3 'sis. The wound was plugged and water dressings applied; anod^mes and nutritious diet administered. The hatmorrhage and hmmopU'sis continued; the right side of the chest became enlarged and the breath fetid. Death resulted October 5th, 1864. Necropsy: A minie ball entered the inferior triangle of the neck, right side, fracturing the first rib obliquely at its middle portion, dei)ressing the st(irnal portion into the apex of the right lung; the dorsal fragment ]n’ojected upward with a sharp pointed extremity, which perforated the subclavian arteiw in the second part of its course. The hall then emerged above the spine of the scajnda. The mediastinum and the light pleural cavity were filled with blood. The right intercostal spaces bulged outward. The heart was forced over to the left. The right lung was collapsed. There were traces of periosteal inflammation on the anterior surfaces of both portions of tlio rib. The appearances of the artery, well represented in Fig. 241, indicated that the laceration had been produced either at the time of impact of the missile, or by some sudden movement of the shoulder, rather than by gradual attrition. The rib is drawn half size in Fig. 240. The speci- mens were presented by Acting Assistant Surgeon W. Leon Hammond. Fig. 240. — Oblique gunshot fracture of right first rib. Spec. GOTO, Scot. I, A. M. M. Fig. 241.— Fcrforiition of right subclavian by the shai'i) point of a fractured lirst rib. Spec. 0377, .Sect. I, A. JM. M. This patient survived the lesion of the artery sixteen days. That the difficulties to be encountered in an attempt to ligate the subclavian under such circumstances as these arc very great, is illustrated by the following case; that they are not absolutely insur- mountable, especially if the left subclavian is the seat of injury, is shown by two cases recorded in the next Section : Ca.se. — Private Levi Reglea, Co. D, 16th Pennsylvania Cavalry, agiul 2.5 j’cars, by occupation a farmer, was admitted to S.atterlce Hospital, Philadelphia, from field hospital. City Point, on August 16, 1864, with a shot fracture of the clavicle, first rib, and scapula. The ball entered the right chest one inch from the sternum, and immediately over the clavicle, jiasslng through and .splintering-it badly, slightly fracturing the fir.st rib, thence through the right scapula, and lodged beneath the infra-sidnatus muscles, one inch below the middle of its spine, where it could be distinctly felt. When admitted, his general heidth was excellent — although anmmic from the loss of the blood which occurred immediately .after the injury — and the wound ajiparently * Dictionaire de.i Sciences MediedJes, T. II, p. 317. “ Ea cbinirgie cst impuissante contre les IC’sions d(;s artires placfics dans I'intcricur dn cidnc, de la poitrino ct du bas-ventre. Ces lesions sent cssentiellement inortelles, i cause de ITifimorragie elfrayantc qui s'ensuit, et qui no tarde pas, i fipuisor ies forces du inalade ; car les blessiircs dcs arteres, loin do s'obliterer d’elles-ineines, teudent toujours i s'agrandir pur Telfort lat6ral du sang, et par le dcchiremcut des fibres de la tunique musculeuse.” CG 522 WOUNDS AND INJUEIES OF THE CHEST. [ClIAP. V, doing well; both the power of motion and sense of touch were wanting in the arm of the wounded side, thus indicating that there was serious injury to the brachial i)lexus, which was further confirmed by frequent complaint of sharp, shooting pains extending down the arm and forearm to the finger ends. It was also noticed that the pulse was entirely wanting at the wrist, nor could there he any pulsation of the brachial artery, indicating that there was some serious injury or obstruction to the subclavian artery. Ordered water dressings, tonics, and a good nutritious diet. On September 1st, several spiculaj of bone were removed from the wound, wliich continued to do well up to half-past seven o’clock P. M. on September 7th, at which time there was a j)rofuse hmmorrhage from the subclavian artery, by which the patient lost fifteen or twenty ounces of blood in a few seconds. Upon arriving at the bedside, the hmmorrhage was found perfectly controlled by the nurse, to whom I had given explicit instruc- tions as to the manner of making compression, in case haemorrhage occurred. A consultation was immediately called, and it was decided to make digital compression until morning. Accordingly, the acting medical cadets were detailed to perform this duty ; relieving each other hourly. The patient rested comparatively well during the night; in making the changes there was no blood lost; stimulants were freely administered. At fifteen minutes before twelve in the morning, a consultation was again held, when it was decided to ligate the subclavian artery in the second third. Acting Assistant Surgeon Walter E. Atlee, U. S. A., consulting ])hysician, operating. An incision was made, bfit, owing to the condition of the parts, the artery could not be found. During tbe operation all comjtression was removed, but there was not the least haemorrhage. After the operation the patient’s body was cold; the skin moist, with a cold, clammy perspiration ; the tongue clean and smooth, and of a leaden hue; the nails bluish; pulse 112, and very weak; the patient being apparently in a moribund condition. The cadets were again detailed to administer stimulants and to watch, and, in case of haemorrhage, to make compression. Observations by Acting Assistant Surgeon M. J. Grier, who administered an anaesthetic consisting of four fluid ounces of sulphuric ether and two of chloroform : “Pulse, at commence- ment of aetherizatiou, 112, irritable, quick, and feeble, rapidly rising to 130, and becoming quick, thready, and almost imperceptible under the application of the anaesthetic; but upon the removal of which returned to its former condition. Sometimes, when the administration was prolonged, it reached the frequency of 160 — always falling below 115 in a few seconds after the admission of the atmosphere. He was very susceptible to its influence, and was very easily controlled by the occasional application of the sponge. Toward the close of the operation, it was deemed advisable to administer brandy, under which the pulse changed from 115 to about 100, gaining in strength and volume.” One hour after the operation, there was considerable reaction; the pulse 98, general expression better, and the body much warmer. Later in the afternoon the pulse fell to 95, gaining in volume and strength under the influence of the stimulants. At a quarter past five in the afternoon, the hasmorrhage recurred, the patient losing about the same amount as at first — in a few seconds — before proper compression could be made. The second haemorrhage left him exceed- ingly weak, the pulse scarcely perceptible, the countenance blanched, the extremities cold, beaded perspiration standing on the face; very restless; thirst urgent; the mind clear until five o’clock on the morning of the 9th, from which time he began to sink rapidly, without any fiirther loss of blood, and died at eight o’clock. Autopsy elicited the following facts : The clavicle was j)erforated and badly fractured; the first rib slightly fractured just outside of its tubercle; the scapula perforated one inch below the middle of its spine; the subclavian artery lacerated by the passage of the ball as it crossed the first rib, and quite a number of spiculae of bone were driven into it, plugging it up entirely for nearly two inches; the injured part was in a sloughing condition, and the inflammation even extending to within the innominata, thus rendering it evident that the ligation of the subclavian in its second third would have been fruitless. The condition of the artery and surrounding parts accounted for the failure to find the artery, as well as the absence of pulsation. It was also found that the brachial plexus was injured, which accounted for the loss of power and the pain extending down the arm and forearm. All the other organs were normal in structure and perfectly healthy. The case is reported by Acting Assistant Surgeon A. A. Smith. In the next case, the patient survived the injury for two days. It was believed that the subclavian vein was injured. The lesion was on the right side, and it was apprehended that any attempt to remove the plug of lint with which the perforation was tamponned would be instantly fatal, and that the wound approached the innominata so closely that the possibility of placing a ligature on that trunk alone admitted of discussion : Case. — An unknown soldier was wounded at Antietam, September 17th, 1862, by a conoidal musket ball, at short range. The missile entered at the junction of the inner third with outer two-thirds of the right collar-bone, made a clean perforation in the anterior wall of the bone, and largely splintered the posterior portion, and emerged above the right scapula. The wounded man was carried to the field hospital at Keedysville. On admission, he was speechless, and in a fainting condition from loss of blood. The track of the wound was plugged with lint saturated with the solution of the persulphate of iron. The usual restoratives were cautiously administered, and the strictest quiet enjoined. On September 19th, 1862, a deluging haemorrhage occurred, and the patient almost immediately expired. It was found that a spicula of the clavicle had transfixed the left subclavian. The artery was not preserved. The clavicle, represented in Fig. 242, fig. 249.-Longitmlinalfr™shot fracture of the right clawcle. Posterior view. - presented to the Museum by Assistant Surgeon S. A. Reduced one-lialf. Upcc. liiT, Sect. I, A. M. M. Storrow, U. S. A. The case by Dr. O’Keefe, recorded on p. 479, of recovery after alleged “undoubted severing of the left subclavian,’’ will be regarded by few as incontestable. The absence of pulsation in the brachial is explicable by inferring embolism of the axillary. Si^CT. II.] WOUNDS OF THE BLOOD-VESSELS. 523 Wounds of the Internal Mammaiy Artery.— BallingalP tells us that lia?nioiThage from this vessel “ is exceedingly difficult to detect or to control,” and that he has “seen more than one instance of fatal bleeding from this source.” Guthrie,^ whose opinions on every subject connected with the surgery of the arteries are justly received with the most respectful attention, is very facetious at the expense of the “theoretical surgeons” who have occupied themselves with inventions for suppressing this form of bleeding, which, it is consolatory to know, is very rare, — the master informing us in the next sentence that he has never seen a distinct case of it. It will be safer to follov/ the advice of those who have had to contend with such lesions, and to seek for such information on the subject as further experience may afford. Only five or six cases are found on the records, in which wounds of the internal mammary were distinctly recognized. Three of these were treated by compression and styptics and two by ligation. But there are many other recorded instances of wounds near the edge of the sternum, with hsemorrhage yet without hsemop- tysis, in some of which the existence of this lesion may fairly be suspected. As it was fatal in the five cases in which it was detected, it merits serious attention : Case. — Private John B , Co. D, 51st Illinois Volunteers, aged ‘20 years, was wounded at Dalla.s, Georgia, June 3d, 1864, the ball entering ov'er the left side of sternum, near the junction of the second rib, and emerging above the clavicle, fracturing the sternum and clavicle. He was promptly conveyed to the hospital of the 2d division, Fourth Corps, and, on June 20th, was transferred to Hospital No. 8, Nashville. When admitted he was very feeble; pulse small and rapid; cough very severe; pneumonia of both lungs. Expectorants and opiates were given, and the patient improved until July 8th, when colliquative diarrhoea and sweats set in, followed, on the 10th, by severe and profuse haemorrhage from the external wound. The jiatient was much reduced by i)rofuse suppuration and pleuro-pneumonia when the haemorrhage occurred, and was considered so near death that it was dangerous to give anaesthetics or attempt an operation. The opening from which the blood escaped was plugged with lint soaked with solution of persulphate of iron. The haemorrhage was controlled, hut the patient sank and died in twelve hours. Necropsy: Lungs greatly engorged. The sternum was fractured transversely at junction of middle with upjier third. The synchondro- sternal articulations of first and second ribs were torn asunder; sterno- clavicular articulations disarticulated; sternal end of clavicle fractured. The fractured end of the sternum was crushed and jammed into the anterior mediastinum. The arch of the aorta, arteria innominata, right subclavian and carotid, and also the left, were all in situ, without perfora- tion; hut the internal mammary was found in the mutilated muscular ll.-^sue with its mouth gaping; the hasmorrhage evidently occurred from the last mentioned vessel. The specimen of fracture of the clavicle and sternum was preserved and is represented in the cut. Fig. 243, as sent to the Museum. The middle portion of the clavicle was excised, probably X)ost mortem, as there is no record of any operation during life, but, on Spec. 3760, Sect. I, A. M. M. the contrary, a statement that it was thought inexpedient to undertake one. Necrosis had begun to invade the inferior portion of the fragment of the sternum, which had been crushed into the anterior mediastinum. The specimen of the wounded artery was, unfortunately, not saved. The osseous preparation was presented by Acting Assistant Surgeon E. T. Higgins. Case. — Private Ephraim Guyer, Co. D, 151st Pennsylvania Volunteers, aged 26 years, was wounded at Gettysburg, July 1st, 1863, by a conoidal musket ball, which fractured the humerus .and passed along the clavicle and lodged behind the edge of the sternum, upon the internal m.amm. Gross tried to ligate the bleeding vessel, but failed. The [)atient died on the following day. The post-mortem examination revealed a cul de sar, within the pleura filled with blood. The case is reported by Surgeon E. C. Fraiddin, U. S. V., and Surgeon H. Wardner, U. S. V. Fig. 243. — Necrosed fragment of the storimm and portion of left clavicle after gunshot fracture. Kcduccd to ouc-third. * BallixgalL, Outlines of Military Surgery, 5th ed., London, 1805, p. 330. Guthiue, Commentaries, ttc., already cited, p. 517. 524 WOUNDS AND INJURIES OF THE CHEST. [CiiAr. V, The next ease was communicatefl by Surgeon AV. Clendenin, U. S. V., to Dr. John A. Liclell, AE, Traiit de Path. Ert., 5'*"^6d., T. TV, p. Ofi ; Xlir.ATON, Kidmens de Path, chir., T. Ill, p. 4.52 ; EkiCHSEX, Science and Art o f Surgery, Vol. I, p. 438, ohscrv'os that “ the intercostal arteries usually seem to escape ; or at least, if wounded, they do not bleed in a troublesome manner;” LegOUEKT (Chirurgie d'Armee, 2'«*‘ 6d., p. 347), regards most of the cases of wounds of the intercostal arteries cited by authors as fm t contestable ; but admits that the twenty-eight cases collected by Martin {Des Lesions dcs arleres intercostales, I’aris, 18.55) leave little room for criticism. ®Baudens, Clinique des plaies d'armes d feu, p. 213. 526 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V, war* that were treated Ly compression, and cite, in the next Section, those in which ligation was performed, and will there refer to some of the ingenious modes of arresting the lisemorrhage that have occasioned so many sneers. Case. — Private Oscar A. Barnes, Co. F, 20tli New York Cavalry, was wounded, on March 5th, 1864, while sitting in his tent in camp at Northwest Landing, Virginia, by the accidental discharge of a Colt’s revolver in the hand of a comrade. The ball entered between the third and fourth ribs, above and to the left of the left nipple, ])assed through the superior lobe of the left lung, making its exit near the inner border of the scapula, at the origin of its spine, fracturing the bone at this point and lodging under the integuments. Within thirty minutes alter the accident the ball was extracted, together with several small j)ieces of bone, through an incision made through the integuments. Ha'moptj’sis and profuse hatmorrhage from the intercostal artery having set in, the wound was plugged with lint and cold-water dressings were applied. The patient was placed on the wounded side and perfect rest was enjoined. Opiates were freely administered. Expectorants were given to assist in relieving the lungs. As soon as suppuration appeared, the dressings were changed, and warm cataplasms were applied. The patient continued to expectorate bloody sputa for five days after the rece])tion of the injury, after which he steadily improved. By the end of the month he had so far recovered as to be able to walk about. On July 31st, in the following year, he was mustered out of service. In April, 18G7, the man was examined by Dr. George JI. Cook, pension examining surgeon at Syracuse, New York, who reports him suflering from expectoration and frequent formation of abscess of the lung; also from lameness, resulting from a gunshot fracture of the metatarsal bone of the left foot, the disability being rated one-fourth for tlio latter wound and three-fourths for that of the lung. This pensioner was on the rolls in March, 1872. The case is reported by Assistant Surgeon M. W. WTlson, 118th New York Volunteers. Case. — Private George Goodwin, Co. H, 100th New York Volunteers, aged 19 years, received a gunshot wound of the right lung during the attack on Fort Darling, May 16th, 1864. He was treated for a few days at the field hospital of the Tenth Army Corps, and subsequently at the Broad and Cherry Streets Hospital, Philadelphia. On June 23d, a hmmorrhage occurred from the intercostal artery. From six to ten ounces of blood were lost, when the haemorrhage was checked by the application of jiersulphate of iron, aided by a compress. There was no recurrence afterward. On the following day, the jiatient had an attack of rubeola. He soon convalesced and improved steadily, and was soon able to leave for his homo on furlough. On August 26th, 1864, he was returned to his command entirely lecovered. He is not a pensioner. Surgeon John Neill, U. S. V., reports the case. In tlie two following fatal cases of liaemorrhage from the intercostal arteries, the patients were apparently exhausted by bleeding prior to their admission to hospital: Case. — Private Anson A. Barrett, Co. E, 12th U. S. Infantry, was wounded at the battle of Cedar Mountain, August 9th, 1862, by a musket ball, which entered three inches to the left of the sternum, at the inferior margin of the first rib, and emerged near the sixth dorsal vertebra, severing in its course an intercostal and one of the larger bronchitd arteries. He was conveyed by rail to the Third Division Hospital, at Alexandria, where he died from the efi’ects of hasmorrhage, on August 17th, 1862. Case. — Private Charles Hale, Co. F, 22d Massachusetts Volunteers, was wounded at the battle of Rappahannock Station, November 7th, 1863, by a fragment of a shell, which produced a severe fracture of the right side of the chest and rupture of an intercostal artery. Two days after the reception of the injury, the wounded man reached the Finley Hospital, where the bleeding was imperfectly controlled by compresses and styptics. The jtatient died on the following day from the effects of hemorrhage. Surgeon B. B. Breed, U. S. V., reports the case. Ill the next three cases the arterial lesions were verified at the autopsies. Two of them were complicated by hamiotJiorax. Case.— Priv.ate Edward Fanning, Co. M, 1st Missouri Cavalry, was accidentally shot through the thorax at Cape Girardeau, Missouri, on December 19th, 1863. He was conveyed to the post hospital, where he lingered until December 30th, 1863. The post mortem examination disclosed that the missile, a conoidal pistol ball, had entered above the right nipple, passed through the sternum and upw'ard, splintering the third rib, left side, and wounding the intercostal artery, thence going into the left shoulder, fracturing the head of the humerus and lodging in the glenoid cavity. The thoracic cavity was found to contain two quarts of yellowish blood. The lungs were congested and the left pleura was inflamed and softened. Reported by Acting Assistant Surgeon Patiick Gilroy. Ca.se. — Private Joseph Kreider, Co. E, 45th Pennsylvania Volunteers, received, at Campbell Station, East Tennessee, November 16th, 1863, a penetrating wound of the thorax by a conoidal ball. On the same day, ho was admitted to Asylum Hospital, Knoxville, where he died on December 1st, 1883. Post mortem showed that the ball entered between the third and fourth ribs, three inches from the median line, fracturing fourth and fifth ribs, right side, wounding intercostal artery, and emerged between seventh and eighth ribs, five inches below axilla, same side ; there was extensive inllammation of upper and middle lobe of right lung ; lower lobe collapsed ; cavity between pleura puhnonalis and jtleura costalis filled with blood from a secondary hmmorrhage, which had been both internid and external. The case is reported by Surgeon C. W. McMillen, 1st Tennessee Mounted Infantry, by whom the autopsy was made. *Iii the tenth edition of liis favorite Vadu Mccuni (p. 484), Dr. Druitt, after advertin'^ to Mr. Lawson's statement that “the intercostal artery was not once secured in the Crimean campaign,” cites Circular No. G, S. G. ()., 1805, as authority for the assertion: “ the same was the case iii the American war.” On page 71 of tliat report two oases <»f ligation (.f the intcrcxistal are r('foiTed to. Sect. II.] WOUNDS OF THE BLOOD-VESSELS. 527 C.v.sK. — Lieutfiiaiit .Toliii S. Ddbinson, Adjutant 7tli Illinois Volunteei's, was woundpd at the l)attl(M)f Allatoona Bass, Georgia, Oetober utli, 1S64, hy a eonoidal musket ball, which entered near the inferior angle of the left scapula and emerged antenorlv, fracturing the sixth rib, ])enetrating the left lung, and tearing an intercostal artery. Copious bleeding from the ante- rior oj)ening, together with expectoration of blood, followed the injury. The limmorrhage was checked by the application of persidphate of iron. After this, tincture of veratruin viride was administered for about two weeks. The jiatient remained at the field hospital of the 4th division. Fifteenth Corps, for over four weeks, being greatly debilitated and in bad health at first, t)ut mending sufficiently to bear transportation to a general hospital on November 3d. On the following day, he reached Ilosjjital No. 1 at Chattanooga, Tennessee, where he died on January 4th, 1865. Surgeon T. R. Zearing, 57th Illinois Volunteers, l eports the wound, and Surgeon J. II. Phillips, U. S. V., the termination of the case. In the seven foregoing instances, hEemorrhage was primary in four, intermediary in one, and secondary in one, and resulted from wounds hy musket balls in four cases, from pistol balls in two, and from a shell fragment in one. The injuries were inflicted on the right side in four and on the left in three cases, and were associated in four cases at least hy perforation of the lung. Nearly all of the wounds were in the space hounded hy the third to the sixth ribs, inclusively. Compresses and styptics were the only local measures employed. This subject will be continued in the next Section. Bleeding from laceration of the pulmonary tissue will be considered in connection with hsemothorax, empyema, etc., in the observation at the close of the Chapter.* Other Lesions of Blood-Vessels. — Specimen 1640, of the Army Medical Museum, is an example of the rare lesion of a rupture of the left subclavian pem.j* C.\SE. — Valentine K , commissary detachment, was caught between the buffers of two railway cars, July 26th. The humerus, clavicle, and scapula were fractured, the neighboring soft parts wore pulpificd, though the skin was unbroken. The left arm became sphacelous, and the patient died July 2od, 1863. The subclavian artery was obliterated, where it leaves the first rib. The subclavian vein- was torn and had supplied the blood which distended the soft ])arts. Assistant Surgeon W^. Thomson, U. S. A., presented the specimen and memorandum. Specimen 2721, shows a bayonet wound of tlie riglit subclavian, near the innom- iiiata, opening two-thirds of the cylinder of the artery. It is from a soldier killed at Fort WaGiner. O Aneurism. — False diffused and consecutive aneurisms were among the secondary con- ditions rarely observed after gunshot wounds of the thorax. J The following is an exain})le, and a few others will be cited in the next Section : Case.. — Private J. H. Carpenterj Co. C, 4th Virginia Cavalry, aged 28 years, \vas wounded on May 12tli, 18G4, hy a niinid ball, which entered one and a half inches below the inner third of right clavicle, making exit one inch from and parallel to posterior border of right axilla. On May 15th, he was admitted to Chimborazo Hospital, liichmond, Virginia. The patient spat blood at the reception of the wound and for several days afterw’^ards ; and on May 20th, hseinorrhage occurred from a branch of * Consult Harder, Diss. dc hsemorrhagia arterim intcrcostalis sistenda, Berolmi, 1823; Assalint, Manuale dC Chirurgia, Milano, 1812. p. 57; EavatON, Pratique inoderne de la chirurgie, Paris, 1785, Vol. II, p. 130; ClIEiauS, Vber die Verlctzung dev Art. intercostalis in Ileiclelberger klinisebe Anualen, B. I, T. IV ; Gaxt, Science and Practice of Surgery^ p. 884 ; VELPEAU, Nouv. £,le. de Med. Op., T. II, p. 2G5; IIAIIRISON, Surgical Anatomy of the Arteries, 4th ed., Dublin, 1839 ; Fraser, P. A., Treatise on Penetrating Wounds of the Chest, Loudon, 1859, p. Ill ; SaxsOX, Des heniorrhagics traumatiques, Paris, 1836, p. 252. tNo example of gunshot wound of the subclavian vein is reported as having come under treatment, unless the case mentioned on pa^^ 522 be regarded as such. The case reported by ]\Ir. Blenkins (Fraser, op. cit., p. 13), where a ball passed between tbe right subclavian artery and vein, wounding the latter, and causing fatal phlebitis, remains the solitary recorded instance. But, as Mr. Fraser observes, the exemption is ideal rather than real, for probably a large proportion of those killed on the field of battle die from tom blood-vessels. J Traumatic affections of the great blood -vessels of the chest arc usually passed over cursorily by systematic authors, and our information concerning these is scattered through theses, monographs, journals, and collections of cases. Leuouest {op. cit., p. 3.33) quotes a unique instance of recovery from a punctured wouud of the aorta, obser\'ed by Dr. Neil of Bamberg, in 1812 (Henke's Zeitschrift fur Arzn., Ileft II, 1837, 1839, and Arch. gen. dc mid., 2"® s^rie, 1838, T. II, p. 109), the cicatrix being verified a year subsequently at the autojisy after death from pneumonia. DiCMMK {op. cit., p. 37) saw a young Austrian at the hospital of St. Francis, at Milan, perish from secondary haemonhage four weeks after the reception of a gunshot injury of the pectoral portion of the descending aorta. Blandix {Anutomie topographique, 2d 6d., 1834, p. 287) observed at the Beaujon liospital a young man who survived a short time a pistol wound of the azyges vein, near its tenninal curve. BRESCHET {Jtepertoire giniral d’ anatomic et de physiologic pathologique et dc clinique, T. IV, p. 196) records an autopsy of a youth of twenty-five years, who received in a duel Ji punctured wound of the azygos vein in the curve it describes before emptying into tbe cava near the right side of the body of the fifth dorsal vertebne ; tlic patient suivived three days. TlM.ELS, of Colbcrg {Responsis mcdicis et diaeteiicis, 1668, C. XVI, quoted by Bonctus, Scpulchrctum, Vol. Ill, p. 3."9) records t)ic case of a nobleman, stabbed through the right axilla, between the lliird and fourth rib.s, the blade wouiuling the i>ulmonary artery. Frotliy bleed fiowod externally and there were frequent syncope.s ; but the wounded man lived tlirce days. Specimen 3388, of the Surgical .Section art of pleura covered with layer of lymph, lower part thickened and discolored by pus. Abscess in first lobe completely circumscribing .second lobe; the pericardium contains thirty ounces of a clear colored mahog.any serum, and, together with the heart, was covered with a thick layer of yellowish lymph. The liver was somewhat softened. Acini somewhat indistinct. Spec. No. 1722, Sect. I, A. M. M., shows a wet preparation of the sixth, seventh, and eighth rihs. The specimen shows firm ])leuritic adhesions. Specimen No. 2243 of the same section shows a wet preparation of the heart and pericardium. Both of the serous sinfaces are shaggy with ))rofuse deposits of lymph, which, in the recent state were pinkish in color. Toward the posterior surface the two sides of the pericardium are united. Both specimens were contributed, with a history of the case, by Assistant Surgeon H. Allen, U. S. A. G7 530 WOUNDS AND INJURIES OF THE CHEST. [ClIAP. V, Wounds of the Heart. — It is well known that wounds of the heart are no longer con- sidered, as in ancient times,'-' absolutely and invariably mortal ; but we are still ignorant of the degree of injury the organ may sustain without destruction of life, and can only con- jecture the causes of delay in the termination of some rare cases presenting lesions that are generally instantly fatal. The diagnosis is very obscure. Hsemorrhage, syncope, pain, dyspnoea, proscordial anxiety, pallor, husky voice, thready pulse, excessive thirst, emesis, hiccough, cold sweats, palpitation, a systolic bellows murmur or other abnormal sounds, many or all of these may attend a wound in the cardific region without establishing more than a presumption that the heart itself is wounded. A peculiar friction sound has been suggested as pathognomonic of traumatic pericarditis; but few surgeons can have occasion to familiarize the ear with this semeiological refinement. In the cases that survive for any length of time, the prognosis will, of course, be very guarded, and the treatment, after closing the wound, will be limited to absolute bodily rest, and the employment of those measures tending to moderate the heart’s action, unless the dyspnoea induced by distention of the pericardial sac should justify the withdrawal of the extravasation by paracentesis. f A perusal of the conflicting views of writers respecting the relative danger of injuries of the different cavities of the heart, and even in regard to the gravity of superficial wounds, and their frequently indefinite descriptions of the remote structural changes ob- served, admonish us that further careful clinical and pathological observations are requisite to elucidate these points. Though many of the cases that appear on the surgical records of the war are not of this character, yet no apology need be made for presenting all the facts that have been ascertained on this difficult and interesting subject. Four instances of gunshot wounds of the heart that were not immediately fatal appear on the records. In the first, the patient survived for fourteen days a wound of the right auricle by a round musket ball : Case. — Private Jacob Lanning, Co. A, 51st Pennsylvania Volunteers, aged 45 years, was wounded at South Mills, North Carolina, April 18th, 1862 ; the missile entered through the lower jaw, carried away the symphysis, passed down the left side of the neck, and lodged in the thorax. He was taken prisoner and remained in the enemy’s hands until the 24th, when he was released at Norfolk and conveyed to Hygeia Hospital, Old Point Comfort. The tongue was destroyed to a considerable extent, and that portion of the jaw occupied by the incisors was comminuted and distributed along the course of the ball. An incision was made in the lower part of the neck to give exit to the pus, and through this opening the finger could be passed down into tbe chest. The case appearing hopeless from the first, little was done except to sustain and stimulate. The patient persisted in sitting up and would occasionally attempt to make up his bed and walk about the room when not restrained. He died suddenly. May 2d, 1862, fourteen days after the reception of the injury. At the necropsy, the ball was found to have descended over the aorta, down the mediastinum, penetrated the muscular tissue of the right auricle, and was suspended in the endocardial cavity. Evidence of pleuritis and pericarditis were apparent after, though not before, death. The case is reported by Surgeon E. B. Bontecou, U. S. V. * Hn’POCllATES : Aphorism XVIII, Sect. G; Celsus (Lib. V, cap. 26) : “Servari non potest cui cor percussum est,’’ and, farther on ; “ Corde percusso. matura mors sequitur." Galen’s prognosis is hardly less gloomy (Z)e locis affect., Lib. V, cap. 2) : “ Protinus liominem mori necesse est," and "Igitur, si ad ventrem cordis vulnus aliquatido penetraverit, protinus magno cum sanguinis fluore moriuntur, id que precipue, si sinistrie partis venter fuerit vulneratus.” t Several authors have made collections of cases of wounds of the heart. The latest and most complete perhaps is by Dr. GeOEG FisCHER, of Hannover, who, in an article in von Langcnbcck’s Archiv fur KUnische Chirurgie, 15. IX, IL II, S. 571, Berlin, 1868, enumerates four hundred and fifty-two cases, of which forty-four, with ten recoveries, were punctured wounds ; two hundred and sixty, with forty-three recoveries, were punctured incised wounds; seventy -two, with twelve recoveries, were gmishot wounds; seventy-six, with ten recoveries, were contusions and traumatic ruptures. M. J.LSIAIN (Plaits du cceur. These de coucours pour I'agregation, Baris, 1857, 8vo. p. 100) has analyzed one hundred and twenty-one eases. Dr, Purple (New York Journal of Medicine, 1855, N. S. Vol. XIV, No. Ill, p. 411), with his Statistical Observations of Wounds of the Heart, has compiled a table of forty-two authenticated eases of wounds of the heart that were not immediately fatal, twelve being injm-ies from gunshot. OLLIVIER (d’ Angers) records (Diet, de Med., 1834, T. VIII) fifty-four cases of wounds of the heart, and SaxsON (Plaits du occur, Thdsc, 1827, p. 16) enumerates the more important cases cited by his predecessors. Dupuytren (Leqons orales, 2™' fed.) refers to fourteen cases, four of which came under his own ohseivation. Fournier gives several examples in his Cas Pares (Diet, de Sci. Med., T. IV). Ciiastanet (Journal de Midecine Uilitaire, Baris, 1783, T. II, p. 377) has collected many cases from Bonetus, Morgagni, and others, and recorded fivm highly interesting observations of his own. I have grouped together (Otis, A Peport of Surgical Cases, etc., 1871, p. 33) twenty-one cases of wounds of the heart observed in the Army of the United States from 1865 to 1870, eighteen being gunshot, ^wo incised, and one a punctured wound from an arrow. Skct. II.] WOUNDS OF THE HEART. 531 The next case refers to a patient who lived an hour and a quarter after a perforation of the right auricle and left ventricle by a conical pistol ball : CaSk. — Private Charles T , 1st Maryland Potomac Home Brigade, aged 25 years, received a pistol-shot wound of the left side in an affray with the provost guard at Frederick, Maryland, February 14th, 1862, at about 11 P. M. The jx'rson discharging the pistol was standing within a few feet of T , who had his left side turned toward him. The bullet entered just over the fouith rib, on a line with the anterior fold of the axilla. The patient immediately became much prostrated and speedily unconscious, with much jactitation and labored respiration, but no ha3mo])tysis or emphysema was observed. He was first seen about 11.30 p. M. On auscultation and percussion the action of the heart w!is weak and tumultuous, and the left side of the chest exhibited marked duluess, indicating effusion of blood into tlie pleural cavity. He died at 12. 15 a. M. The necropsy, twelve hours afterward, revealed a fracture of the fourth rib, a wound of the lower and anterior portion of the upper lobe of the left lung, which track was found continuous with one passing through the left ventricle of the heart about its centre, and emerging at tlie riglit auricle; thence it passed through the outer and upper portion of the middle lobe of the right lung, and terminated by a small puncture of the pleura costalis over the fifth rib. The bullet was found in the right pleural cavity, which, like the left, contained about fourteen ounces of effused blood. The pericardium also contained about four ounces of blood. Surrounding the track of the wound in the pulmonary tissue, was a mass of coagulum, which explained the absence of haemoptysis and emphysema. The bullet was the ordinary conical one used in revolving pistols. A w'et preparation of the heart is Spec. No. 837, Sect. I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon K. F. Weii-, U. S. A. Circular No. G, 1865, states erroneously that the patient “survived twelve hours.” He died near twelve, midnight. The third is an example of perforation of the left auricle and left ventricle by a pistol ball. The patient lived forty-six hours after the reception of the injury, although the case was complicated by wounds of the abdomen and axilla : Case. — Private Lewis Wright, Co. C, 4th Regiment, Veteran Reserve Corps, aged 28 years, was wounded at Quincy, Illinois, September 8th, 1864; he was assaulted by an intoxicated citizen, who fired several shots at him, three of which took effect; one, an inch above the crest of the ilium, in the middle line of the left side ; another through the anterior boundary of the axillary space, and the third on the right side of the back, about two inches exterior to the inferior angle of the scapula. The patient when brought to the hospital was cold and almost pulseless, though conscious. He complained of a general sense of indescribable suffering and unquenchable J;hirst ; very little hsemorrhage had taken place. The situation of the balls could not be ascertained. Anodynes, diffusible stimulants, friction, and artificial heat were resorted to, but any means to bring on reaction proved unavailing. The patient lived just forty-six hours after the reception of the wounds. At the post mortem examination of the body it was found that the first ball had entered above the crest of the ilium, passed directly into the cavity of the abdomen and into the intestines. The second simply passed through the anterior boundary of the axilla from below upward. The third entered the chest at the point specified, fractured the posterior third of the eighth rib, entei’ed the right lung about its middle, passed through it and into the left auricle of the heart, thence through the auriculo-ventricular opening to the left ventricle, making its exit about the middle of the lateral aspect of the organ, thence through the pericardium, and could be traced no farther. The balls entering the body were small, which made the track difficult to trace through the different tissues, so much so that with the utmost care and perseverance no ball was found. A pint or a pint and a half of blood was found in the right chest. Acting Assistant Surgeon J. T. Wilson reports the case. In the fourth case, the testimony of the existence of a cicatrix of a musket-ball wound of the right auricle, and of softening and rupture of the muscular tissue, two and a half years after recovery from the injury, is very positive ; Case. — Private John Reynolds, Co. D, 1st Michigan Sharp-shooters, aged 42 years, received a gunshot wound of the left breast and shoulder at Spottsylvania, Virginia, May 12th, 1864. He was conveyed to the field hospital, where simple dressings were applied to the wound. On May 25th, he was transferred to the 1st division hospital, Alexandria; on February 25th, 1865, to Fairfax Seminary Hospital, Virginia; on April 4th, to St. Mary’s Hospital, Detroit, Michigan, and on May 26th to Harper Hospital, Detroit, whence he was discharged from service July 14th, 1865. He died at Mattawan, Van Buren County, Michigan, November 22d, 1866. Apost mortem examination was made by Drs. David Brown and Nathan M. Smith. The ball entered the body between the fourth and fifth libs on the left side, passed upward and backward and emerged between the clavicle and scapula of the same side, wounding in its passage the anterior surface of the auricle of the heart, producing the appearance of a cicatnx on said auricle, organic lesion resulting therefrom, and subsequently decay and rupture of the auricle, causing almost instantaneous death. All the vital organs except the heart were healthy. Without the slightest disposition to impugn the accuracy of the conclusions of Dr. Brown and Dr. Smith regarding the morbid conditions observed at the necropsy, I may be permitted to ask if the paucity of details concerning the wound does not warrant a certain skepticism as to the relation sought to be established between it and the appear- ances noted at the autopsy. It is known that the milk spots (Tiiaculce albidce) of Rokitanski have been mistaken for cicatrices. 532 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V, That death is apparently absolutely instantaneous after some wounds of the heart is generally conceded, yet the absence of all automatic muscular movements is uncommon. Diemerhroeck describes [Anat. Corp. hum., Lib. VI, c. I) a man receiving a sword thrust in the chest, and falling dead instantly : Quasi fuimme ictus concidit moxque extmctus est, and in many cases of military executions death is pronounced to be instantaneous ; but the extinction of vitality, resulting from the sudden gush of blood, rarely resembles that caused by the lightning stroke, the sideration of chloroform, woorara, or prussic acid, or by a wound of the medulla oblongata. Mr. Poland correctly observes {loe. cit., p. 608) that “the popular notion of persons springing up in the air, when shot through the heart, is not verified by facts.” There is a hurried exclamation or a convulsive gasping not infrequently, and the phenomena usually attendant on sudden syncope or collapse, are, according to Herr Fischer’s statistics, those that commonly predominate. The two following abstracts, the first by a distinguished writer on military surgery, the second a tragi-comic account of the homicide of an officer fleeing from his friends, graphically depict sudden deaths from heart wounds Case. — Private Edward Barrett, Co. F, 32d New York Volunteers, was shot by a sentinel at Camp Newton, Virginia, January 30th, 1862. Medical Inspector Frank H. Hamilton, U. S. A., in a report of the case in the American Medical Times, Vol. VIII, p. 193, says; “Assisted by Surgeons Little, Brown, Totten, and others, I made an autopsy on the same day. The ball had entered on the left side of his chest about four inches below the inferior angle of the scapula, striking and breaking the lower margin of the eiglith rib and carrying some small fragments into the track of the wound. The wound of entrance was rather smaller than an ordinary musket ball, oval, its edges slightly inverted and surrounded with a reddened areola, caused by the integument being sliglitly abraded or deprived of its cuticle Ity the pressure of the ball before it penetrated the tissues. From this point the track of the ball passed through the free margin of the upper lobe of the left lung, making a contused, but not lacerated, cylindric.al channel, which channel was surrounded through its whole length by an ecchymosis of .about one inch in diameter. The ball then penetrated both ventricles and the right auricle, and through the upper Iqbe of the right lung, escaping in the right axilla. The track through the right lung presented the same appearance as that through the left; and the wound of exit was larger by one-half than the wound of entrance, somewhat oval also, the edges not everted, but looking discolored, as if they were blackened by )iowder. This discoloration was found to be due to a slight extravasation of blood into the tissues under the skin. The heart was firmly contracted and contained no blood in any of its cavities ; but the pericardium contained about eight ounces, and the two pleural cavities much more. The lungs were completely collapsed. The wounds in the several cavities of the heart were not in any instances more than three lines in diameter, and appeared like slits, as if made by a pointed instru- ment. After this man was shot, he uttered one exclamation and fell apparently dead.” Case. — “Lieutenant Dennis H. J , Co. I, 55th Massachusetts Volunteers, was accidentally shot through the heart by a fellow-officer at Yellow Bluff, Florida, March 23d, 1834, while they were attempting to escape from an apprehended attack by the rebels. In the hand of the latter officer was a Smith and Wesson revolver cocked, which was discharged as they both slip])ed and fell together at the edge of the water into which they were trying to drag their boat. J instantly fell back into the water, only exclaiming twice “ save me! save me!” evidently under the impression that the shot came from the enemy ; his face also expressing rather terror at the repoi't than bodily pain from the wound. For an instant he convulsively grasped the rope, but soon let go, and with one gurgling respiration both heart and lungs appeared to have ceased to act within half a minute. The supjiosed rebels proving to be a pai'ty of engineer soldiers from this post, the non-recognition having been mutual, the body was recovered and brought to the post hospital ; no further sign of life was manifested, except a sort of groan when the body was raised, about five minutes after the accident, which may well be supposed to have been the result of the sudden displacement of the large quantity of fluid in the cavities rather than of any conscious volunt.ary action. The accident occurred at five o’clock P. M. Necropsy: liigor mortis slight. Surface of body very pale and rather cool. The single external wound was veiy small and situated tw’o inches below and a little inward from the left nipple. There had been no external haemorrhage, but on op(>ning the chest more than three quarts of blood were found in this cavity and that of the pericardium, the lung being compressed against the anterior parietes. From its entrance between the fifth and sixth ribs, the ball had passed almost directly backward, inclining obliquely toward the middle line, perforating the pericardium and the heart near its apex, so as to leave two openings in the pericardium and left ventricle, and had buried itself, base foremost, in the body of the eleventh dorsal vertebr.a, but without entering the spinal canal. The wound of entrance of the heart was one inch above the apex of the organ and close to the interventricular septum ; that of exit was one inch and three-quarters above the apex and three-quarters of an inch from the septum. The former was small and one-fourth of an inch in diameter throughout; the latter was one-fourth of an inch in * For (lescri])tions of sudden deaths from wounds of the lieart, consult IlELWio ( Observationes mcdico-physicee, 4to, Augsburg, 1800, Ohs. 08) ; PlilOU (Mimoires sur les plaics pinelraulcs cU la 2 >oitrine, in Mem. de I'Acad. roy. de Med., Paris, 1833, T. II, p. 420) — an armorer falls dead without uttering a word, the heart traversed lengthwise by two pistol balls; TiMAlUS {Casus nted. jirax., Leipzig, 1077, Lib. VI. Obs. 38), subitoque concidens, ilUco mortuus est; OLLiviEii (1. c., p. 240), three cases of stabs of the left ventricle ; heart contracted and empty. It is probable that the rapidity of death is due not to the profuse bleeding, as Sexac (Traite de la structure du caeur, Paris, 1749, T. II, p. 371) supposed, but to the obstacle to the cii-culation caused by distension of the pericardium as Morgagxi (1. c., ep. 07) explains. Sect. II.] WOUNDS OF THE HEABT. 533 diameter at its inner extremity, but greatly increased in calil)re from within outward so as to be of a conical shape, with edges somewhat torn. Tlie columni® carnea; on the septinn were barely grazed in one spot, whence it may he inferred that the ventricle was dilated when struck by the hall. The contrast between the two wounds suggests the idea that the invei-sion of the halt may have been caused by the contraction of the po.sterior w'all of the ventricle at the moment of perforation. Both the ventricles were empty.” Spec. 2039, Sect. I, A. M. i\I., is a wet preparation of the lower part of the heart; the missile is attached. It was contributed, with a history of the case, by Assistant Surgeon Burt G. Wilder, 55th Massachusetts Volunteers. Cardiac Diseases resulting from Wounds. — A number of cases are found on the hospital records of functional or organic diseases of the heart, confidently referred to the remote effects of gunshot injuries of its envelope or the tissues in the immediate vicinity. Some of these cases are carelessly alluded to by clerks or pension examiners as recoveries after wounds of the heart. The following are examples of this group of cases : Case. — Sergeant Herrick Hodges, Co. I, 17th Michigan Volunteers, was wounded at Antietam, ^Maryland, September 17th, 18(32; the hall entered the left chest, passed through the seventh rib, and lodged in the lung; he also received a wound through the calf of the left leg. He was treated in the field until October 3d, when he was transferred to Frederick, Maryland, in the hospitals of which place he remained until January 27th, 1863, when he was returned to duty. He was discharged from service at post hospital, Detroit, Michigan, June 1st, 1863. Pension Examiner H. O. Hitchcock reports, under date of February 12th, 1864, that the hall still remains in the chest, causing great functional disturbance of the lieart, pain, and ])rostration. Disability total. Case. — -Lieutenant J. II. Allen, Co. G, 15th Virginia Infantry, received a gunshot wound of the left lung, implicating the pericardium, at Antietam, ilaryland, September 17th, 1862. He was subsequently retired from service on account of endocarditis, resulting in structural change or organic disease of the heart, which rendered him perfectly unfit for field service. Tlie case comes from a medical certificate for retirement, signed by the members of a Confedeiate Examining Board. Case. — Private Alexander Smith, Co. I, 100th New York Volunteers, aged 37 years, is reiiorted by Surgeon M. S. Kittinger, 100th New York Volunteers, as having been discharged from service September 9th, 1862, on account of a gunshot wound through the right lung. Pension Examiner H. N. Loomis reports, October 19th, 1866 : “ The hall entered about three inches to the left of the spine and about the same distance below the apex of the scapula, passed between the ribs and through the left lung and escaped one and a half inches below the left nipple. The wounds are healed externally. He has constant cough, with expectoration of muco-purulent matter, which, in the mornings, is mixed with blood. He has distinctly marked hypertrophy of the heart. The throbbing of his heai't can he seen across the room. Pulse 92 and irregular. He is emaciated and weak, and has laborious breathing, accompanied with pain and a distressing sense of suffocation when lie exercises. The cough and expectoration undouhtedlj' proceed from the unhealed wound of the lung. There is no doubt that the disease of the heart originates from the passage of the ball so nearly in contact as to produce oi'ganic change, first from the shock and then from subsequent inflammation.” Smith died August 10th, 1869, of “hypertrophy and valvular disease of the heart, resulting from the wound.” His attending physician has attended him for sixteen years and says- he was a healthy man. His reasons for disputing the examiners statement are not given. Case. — Private Jacob Bang, Co. D, 76th Pennsylvania Volunteers, aged 23 years, was wounded in the left breast by a conoidal ball, at Petersburg, Virginia, July 30th, 1864. Being at once conveyed to the field hospital, simple dressings were applied to the wound. On August 2d, he was transferred to the hospital at Fort Monroe; on the 7th, to De Camp Hospital, New York Harbor, and on September 13th, to Satterlee Hospital, Philadelphia, whence he was returned to dutj^ October 19th, 1864. On October 24th, he entered Augur Hospital, Virginia, and was discharged from service January 1st, 1865. Pension Examiner H. S. Huber reports, February 2d, 1871 : “The ball entered the chest one inch above the nipple, passed directly through the left lung, and emerged just below the lower angle of the scapula. Slight dulness on percussion and feeble respiratory murmur in the vicinity of the cicatrix. Disability total and permanent.” It is added that the heart was injured. Ca.se. — Private John W. Hopper, Co. B, 79th Indiana Volunteers, was admitted to Hospital No. 1, Louisville, Kentucky, February 28th, 1863, with a gunshot penetrating wound of the chest, received at Murfreesboro’, Tennessee, December 31st, 1802. He was discharged from service March 29th, 1833. Pension Examiner Wilson Lockhart reports. May 15th, 1863 ; “ The ball entered the posterior portion of the left lung and lodged somewhere in the region of the heart, afl'ecting its circulation in such a manner as to induce a general dropsical condition. Pain and dulness at seat of injury. Disability total and permanent.” Formerly punctured and incised wounds of the lieart were met with most frequently,"'' but, at the present day, injuries from fire-arms are much more common. Of twenty cases *The earlier recorded examples of temporary surviTal of wounds of the heart are mtiinly instances of stahs by swords or daggers. l*arc was one of the first {in Lib. Vllf, c. 32) to refute the prevalent doctrine that wounds of the heart were instantaneously mortal, adducing the example he saw at Thurin, of a duellist, who, after receiving a sword thrust in the heart large enouglt to admit the finger, pursued his (.ppe-nent, thrusting at lum several times, for two hundred paces, and then fell dead. Among the more interesting cases of wounds by the sword or knilc arc those rcconled by I’Eltcv (SaxsOX, obs. 19), where the patient lived nine hours after the right auricle was freely laid open ; — by Lilly {Zodiactis vu’.fUco-gaUicus^ ( ienevui, Aprilis, 1080, obs. X), whose patient lived five days after a swonl wound of the riglit auricle. Dr. Hillings lias recently acquired a copy of this very rare work, the first medical journal ever published, for the Surgeon (ieneral's Library. IJilly's case is cited in the Sejmlchrctnni of Ilonctus, 'i'. Hi. ji. 37(), and by Dllivier (?. c., i>. 2.rJ) ; by LnilOUGK (in his edition of Saviard s Uacucil d' obse.rvalions 'dc Chin/rgic, 1792, obs. 1 13), of a soldier W’ho resumed his avocations on the ninth day after receiving a stab in the right auricle, and died suddenly on the eleventh day at a cabaret. Ollivier reganls wounds of the right ventricle as not imly the most common but the least promptly fatal. For incised or punctured wounds of this cavity, see the cases 534 WOUWDS AND INJURIES OF THE CHEST. [Chap. V, observed in tlie Army in the five years succeeding the war, eigliteen were from gunshot, and two from stabs by knives. One of the latter furnished the Museum with a remarkable example of solution of continuity of bone by incision, as well as one of the heart with a gash in the right auricle. The specimens of incised wound of the heart referred to and illustrated by the accom- panying wood-cuts (Figs. 244 and 245) were taken from a man killed in an affray at Fort Dodge, Kansas, June 2d, 1867. He had inflicted, with a large sheath-knife, several stabs upon his antagonist, when the latter, seizing his wrist, turned the point of the knife toward him, and suddenly drove the blade with great force into his chest, the handle still being grasped in his own hand. He fell at once, gasping for breath, his face deadly pale, and expired in about eight minutes. Assistant Surgeon C. S. De Graw, U. S. A., made an autopsy on the fol- lowing morning. After cleanly dividing the sternum, the blade had traversed the mediastinum and freely opened the right auricle. The cavities of the heart . , , Fic:.245. — Siernum, were empty, the sac ot the pericardium and the ?i>owing an nwique i incision through gla- mediastinum were filled with blood.^ geeFi. a^mAi. Fig. 244. — Heart, with an in- cised wound of the right auricle. Spec. 4870, Sect. I, A. M. M. The collection of the Army Medical Museum includes seven specimens of gunshot wounds of the heart, — five from pistol balls' and two from conoidal musket balls,^ — a specimen of incised and one of punctured wound,^and two specimens of cardiac disease resulting secondarily from gunshot injury.^ The duration of life after wound of the heart is not proportionate to the extent of the wound.® of Panatioli {latralogismorum seu medicinaUum ohservationes pentacostx quinque, Roma, 1652, Pent. V, obs. 45), life prolonged for four days; and a similar case is reported by JOUERT (Arch. gen. de Mcd.^ 1830, p. 200); those of BARTHOLIN {Hist. anat. et med. rar. Cent. I, Hist. 77) ; Garmann {Ephem. nat. Cur., obs. 114, p. 228); BOTKR (in Fourcroy’s Mtdecine ecclaxree par les set. phys., T. II, p. 92), are examples of incised wounds of the right ventricle, in which the patients sinvived five days. DURAndr reports (Memoire sur Vahus de V ensevelissement des marts. Strasbourg, 1780) a case in which a patient suiA'ived a sword thrust of the right ventricle fifteen days, and N. MULLER, according to Tulpius {Ohs. med., Lib. c. 13), saw a similar case. MORANI) {Opuscules de Chirurgie, Sec. Partie, 1772, p. 184) presented the heart of a soldier to the Academy of Sciences, in 1835, exhibiting, in the right ventricle, a sword cut which caused no gnive symptoms until the fourth day; the patient died on the ninth. Diemerbroeck’S {Anat. Carp, Bum., L. VI) jiatient walked sixty paces and lived ten days after a similar wound. Valsalva’s (in Morgagni’s cases. Opera Omnia, T. II, Epist. 53, art. 4, Patavii, 1765) patient, wounded in the same manner, died on eighth day; AUGE’s on the ninth (Marrigues, Bemarques sxir lesplaies du cceur, Anc. .Tour, de Med., T. XLVIII, p. 244) ; those of Rov (Bonetus, 1. c., T. Ill, p. 357) and Fantoxi {Giornale di-lcttcrale d' Italia, T. XXI, p. 148), not until the twenty-third day. Of sword wounds of the left ventricle, not immediately fatal, COURTIAL {Kouv. ohs. anat. sur les os, 170.5, p. 138) cites a case in which the patient walked five hundred paces and lived five hours; Frisi {II Filiatro Sel^ezio, 1834, p. 37), one of death on the tenth day; Faxtoni (?. c., p. 145), one of a soldier who lived seventeen days. ' See Circular No. 3, S. G. O., 1871, A Report of Surgical Cases treated in the Army of the United States from 1865 to 1871, p. 91. 2 Army I\Iedical ^Museum, Sect. I, Spec. 837, pistol-ball perforation of left ventricle and right auricle, — suiA'ived one hour and a quarter; see details in text. No. 2639, a similar specimen, antero-postcrior perforation of left ventricle near septum, — instant death ; cited in text, also in lioston Med. and Surg. Jour., Vol. LX XI, p. 292. No. 5688, laceration of right ventricle by a ball from a Navy revolver, — death instantaneous. No. 5929, oblique perforation of anterior wall of left ventricle by a small Derringer ball; cavity not open {see Circular No. 3, S. G. O., 1871, p. 33) ; suicide, — lived twenty- seven minutes. No. 5949, pistol-shot through right ventricle, — siUAuved fifteen minutes. 3 Army IMedic.al Museum, Sect. I, Spec. 1052, gunshot perforation of left ventricle {Cat. of Surg. Sect., p. 453). No. 5648, gunshot laceration of right ventricle and auricle (Circular No. 3, p. 36), — death instantaneous. ^Army IMedical Museum, Sect. I, Spec. 4870; cited in text. No. 5958, stab near apex in right ventricle by a jack-knife, — ^ran thirty yards and sunTved twelve minutes. ® Army IMedical I^Iuseum, Sect. I, Spec. 504 ; musket ball imbedded between innominata artery and descending cava, provoking pericarditis ( Cat. Surg. Sect. A. M. 1\I., p. 453). This is the case referred to in connection with wounds of the innominata on p. 520. Further than that it was presented by Siirgeon D. W. Bliss, IJ. S. V., and that it was removed from a patient who died in 1862 in Armory Square Hospital, with a gunshot wound of the chest, no information concerning the specimen or the clinical facts connected with it can be obtained. No. 2243, shaggy deposits of lymph upon heart and pericardium following gunshot wound {Ibid., p. 454). ®This was illustiatcd in Dr. Carvallo’s patient {Spec. 5929, mentioned in foot-note 2), also by the well-known case of Tour d’ Auvergne, first gren- adier.of France, who died immediately from a superficial lance w’ound of the anterior wall of the left ventricle, received at Neustadt, July, 1798. Also by the case of the Sardinian prince, whose wife thrust a gold needle into his right ventricle, causing instant death. (SUE, Aj^er^u general de la mid. leg. In Recueil period, de la Soc. de Med. de Paris, T. VHI, p. 31, and the case of the Due de Berri, recorded and treated by Dupuytren. I have not space to treat of the effect of the direction of tlie wound on the duration of life, or the relative frequency of wounds of the several cavities, or lodgment of foreign bodies in Uie heart, or of rupture of that organ. Sect. II.] WOUNDS OF THE MEDIASTINUM. 535 Shot Wounds of the Mediastinuni.—lt is certain that even large foreign bodies may penetrate or pass through the mediastina, without injuring either lung or implicating any of the important organs contained in the mediastinal spaces. An interesting instance has been adduced (p. 486), and illustrated by Plate X, where the anterior mediastinum was very freely opened by a canister shot, and its contents exposed to view without sustaining serious injury, and the patient rapidly recovered, and now, after ten years, maintains a cheerfulness of temper as admirable as the fortitude with which he bore the suffering at first attendant on his wound. Other less surprising examples are noticed among the gun- shot fractures of - the sternum. The following is an additional case : Case. — Sergeant Janies G. Powers, Co. C, 57th Massacliusetts Volunteers, was wounded at Petersburg, Virginia, July 30th, 1864, by a conoidal ball, which fractured the fifth and sixth ribs, and carried away a portion of the sternum. He also received a fracture of the middle third of the humerus. He was carried to the field hospital of the 1st division, Ninth Corps, where Surgeon W. V. White, 57th Massachusetts Volunteers, administered chlorofoim and ether and amputated the left arm at the junction of the middle and upper thirds by circular operation. He died August IGth, 1864. This case is supposed to be the one alluded to by Assistant Surgeon George M. McGill, U. S. A., medical inspector, in a letter to Surgeon T. A. MeParlin, U. S. A. (then medical director of the Army of the Potomac), dated August 13th, 1864, in which he says : “Among the surgical cases there is one in hospital now of capital interest. The meso-sternum has been broken in two by a ball which lacerated the soft parts over it. The broken pieces of bone have been removed ; the soft parts are gone (by sloughing and retraction after incision), so that an observer looks upon the heart invested with pericardium, and distinguishes plainly the diastole and systole of the auricles; at the same time the apex impulse can be felt. The wound is a human vivisection.” The identification of this case was correct. Surgeon Horace Ludington, 100th Pennsylvania, contributed, May 31st, 1875, a full account of the case, which will be published in the Third Surgical Volume. It is accompanied by a very interesting specimen. No. 6528, A. M. M. Abscess and sloughing of the loose areolar tissue which fill its interstices, attend some of the wounds penetrating the mediastinum : Case. — Private William Eobertson, Co. H, 71st Pennsylvania Volunteers, aged 21 years, received at Antietam, Maryland, September 17th, 1862, a gunshot wound in the anterior mediastinum. He was admitted to Master Street Hospital, Philadelphia, on September 29th. The treatment consisted of nutritious diet and opiates at first; but, in November, the pain in the muscles became severe; yet yielded almost entirely to the use of expectorants ; ulceration of the skin and sloughing of the cellular tissue finally complicated the case, and the patient died from exhaustion on November ,17th, 1862. The case is reported by Surgeon Paul B. Goddard, U. S. V. Wounds of the Thoracic Duct. — Xo instance is found in the surgical records of the war, of a wound of the thoracic duct, verified by autopsy, nor was there any example among the injuries of the chest of a case presenting symptoms that aroused the suspicion that this rare lesion* might be the main feature of the complications. Dr. Fraser observes [ep. cit., p. 101) that in the British army in the Crimea, “ certain cases, where neither the lungs nor large vessels were wounded, but rapid and fatal sinking occurred, may be explained by the supposition that the thoracic duct had been injured.” But the surgical historians of the Crimean war, Matthew and M. Chenu, do not specify such cases. Wounds of the (Esophagus. — Wounds of the cervical portion of this canal have been considered on p. 408. They are usually associated with wounds of the windpipe. * “ Tenement rarcs,” says M. LKGOUEST {op. cit., 6d. p. 330), “ qu'on n‘en possede pasd'exemple authentique : il est juste dcrccunnaitrc qu'clles peuvent passer inaperejues, au milieu du d^sordre des parties voisines qui doit necessairement les accompagner.” IIennen {op, cit., 3d ed. p. 404) remarks : “ Of lesions of the Thoracic Duct, I shall not insult m}’’ readers by treating ; the uncomplicated injury^ is barely possible ; but ai*t can do nothing toward its cure.” I cannot conceive that it is disrespectful to the reader to advert to the sources of our limited information on the subject ; but there may be some obscure reason, since Larrey and Guthrie and Baudens passed it over in silence. I’rofessor S. D. GnOSS {op. cit., Vol II, p. 450) tells us that Blumenbach refers to an instance. I cannot find the reference in J. BitiKDnicn Bi.UMEN'BACII's Medicinische Bihliothek, Gottingen, 1783, in which the author confines himself to anatomical details obseiv'ed by >Subaticr, llewson, and l^ccquct. BONEIUS, hotvever {Sepulchretuin, Vol. Ill, p. 360), cites from Bartholinus several examples of wounds of the chylifei’ous duct, characterized by the escape of a copious white liquid, copiosus albicans humor. ClIELIUS {op. cit., Vol. I, p. 501) remarks that injuries of the thoracic duct may be connected with penetrating wounds of the chest ; but “ as in these cases there must always bo injury of the most highly important parts, the mortal result is usually not to be prevented.” DEMME mentions {Studien, 18G4, p. 114) that in the Italian War of 1850 he could learn of no instance of wound of the lymphatic duct. Buesciiet, in his article Dcchire- ments, in the Dictionary in GO volumes, T. VIll, p. 140, has collected from Morgagni {op. cit., cpis. XVI, § 7), Soemmering (De morh. vasorum absorbent tium corp. hum. p. 52), Willis {Pharm. ration.), Lossius, Monro, Licutand, and others, many instances of spontaneous laceration of the tlioracic duct, but regards the case recorded by Guiffart as alone well authenticated. All the authors refer to the extravasation of a lactescent liquid in tire cavities of the chest and abdomen as the principal sign of this lesion, and generally pronounce it speedily mortal, great emaciation super\'cning. if death is delayed. 536 WOUNDS AND INJURIES OF THE CHEST, [Chap. V, Wounds of tlie thoracic portion must he very rare, as only a solitary instance appears on the reports of the war : Case. — Privute Jolin Henry Jones, Co. E, 15tli New Jersey Volunteers, was wounded at Spottsylvania, May 10th, 18C4, by a colloidal hall, which entered the right arm posteriorly, passed forward and upward, comminuting and carrying away one and a half inches of the spine of the scapula, passed under the clavicle, opening the thoracic cavity behind the carotid vessels, fracturing the transverse processes of fourth and fifth cervical vertebra;, and lodged against the oesophagus. He was admitted to Lincoln Hospital, at Washington, on May 16th, and died May 20th, 1864. Post mortem examination revealed the course of the ball as described. The apex of the right lung was covered with lymph ; there was ecchymosed blood in the walls of the chest, and fluid blood in its cavities. The walls of the gullet were lacerated but not perforated ; the spinal cord was congested, but no clot found in the canal ; the kidneys and liver were congested and the gall bladder was distended. The case is reported by Assistant Surgeon J. C. McKee, U. S. A. In this case, no symptoms peculiar to the wound of the oesophagus are recorded. Boyer [1. c., T. V, p. 606) gives a full account of these injuries, with an interesting case of recovery after bayonet wound. Wounds of the Nerves. — Baudens, whose practical observations it is always a pleasure to consult, declares that wounds of the phrenic nerve are not very rare,^ and that they are indicated by pain in the diajjhragm, by gastralgia, and generally by vomiting. These symptoms commonly subside in ten days or a fortnight, but are reechoed by more persist- ent pains in the shoulder and arm, sometimes associated with paralysis, of which Baudens cites a good instance. Baudens also gives a good case of a gunshot wound lacerating the oesophagus and eighth pair of nerves, which proved fatal in twelve hours. The stomach was half filled with undigested food. There was no extravasation except of blood, for there had been no vomiting and no ingestion of food or drink. This observation corrobo- rates the physiological views which ascribe to the division of the eighth pair low down the arrest of gastric secretion and of thirst and vomiting, the communication between the brain and viscera being destroyed. I have been unable to find in the records any cases that throw light on the effects of injuries of large nerves within the thorax. A priori, it may be inferred that various derangements in the functions of haematosis, digestion and respira- tion would be observed ; but the complicated nature of these injuries appears to forbid any precise analysis. Dr. S. W. Mitchell, in a recent instructive monograph,^ narrates the case of Private Warner, 18th Pennsylvania Volunteers, who received a gunshot injury to the anterior thoracic nerve probably, causing paralysis of the great pectoral muscle, and extension of disease to the brachial plexus. I find no special case of wound of the par vagum or other thoracic nerve noted in the returns. MAunds of the Diaphragm.— The records contain references to one hundred and twenty cases of wounds of the diaphragm that came under treatment. Some of them have been described^ with the wounds of the thoracic viscera with which they were associated, and others will come under notice with wounds of the abdominal viscera. Hence, it will be more convenient to continue this subject further on, where it will be abundantly shown that wounds of the diaphragm, though not invariably mortal, as the ancients be- lieved, rarely heal, and leave always a liability to hernial protrusion.^ ‘Baudens, Clinique des plates d'armes d feu^ Paris, 1836, p. 249. ^Mitchell, S. W., Injuries of the Nerves and their Consequences, Philadelphia, 1872, p. 212. ® See ante, cases of PEiiuiN, p. 514, Stolpk, p. 515, Bowman, p. .516, Sheridan, p. 516. These four are examples of diaphragroatic hernia. For bayonet wound of the diaphragm, see case of IlAY, p. 467. For examples of recovery after gunshot wounds of the diaidiragm, see cases of Iloric, p. 480, Collins, p. 491. See also ease of Ackerman, p. 528. ^ Consult, on this subject, OUTIIRIE ( Commentaries, 1. c., p. 499), BAUDENS {1. c., p, 301), Friderict, Dc diaphr. ex vulnere lucso, Diss. Jenao, 1671 j Schenk, Dc diajthragmatis nat. et morhis, Diss. Jenae, 1671 ; Nelaton, ^Icm. depath, chirurgicale, T. HI, p. 463; LEGOUEST (/. c., p. 363) ; ETIMUL* LEU, Diss. de vulnerihus diaphragmatis, Lipsiae, 1730; PERCY, Diet, de Sci. Med., T. IX, p. 214 ; CLOQUET, Diet, de Med., T. X, p. 259 ; Devergie,, Medicine legale, S™* 6d., 1852, T. II, p. 35; Desault, Jour, de Chir., T. Ill, p. 9 ; Mertens, Vulnus pectoris complic. cum vulnere diaphragmatis Strassburg, 1758 ; CavaliER, Observations sur qnelques lesions da diaphragm, These dc Paris, No. 362. Sect. III.] OPEEATIONS. 537 Section III. OPERATIONS ON THE CHEST. The ligations of the great arterial trunks and of some of their branches, the excisions of portions of the bony case, the extractions of splinters, missiles, and other foreign bodies, and the cases of thoracentesis will be considered in this section. Ligations. — The cases in which it was found necessary, during the war, to apply ligatures to arteries of the chest, were sufficiently numerous, especially when viewed in connection with the examples of wounds of those vessels recorded in the preceding section, to constitute a valuable contribution to our information on this branch of surgery. No example of ligation of the primary carotid within the chest, for wound or aneurism, appears on the returns, and in the few cases of lesion of the innominata that came under treatment, it was not deemed feasible to place double ligatures on the vessel. Ligations of the Innominata. — In the seventeen cases ^ in which this vessel has been tied, the operation was performed for traumatic cause in only a single instance, — when Hutin, after tying the subclavian, after Anel’s method, for punctured wound of the axillary, on the appearance of intermediary haemorrhage, placed a ligature on the brachio-cephalic. The patient survived the operation twelve hours. Success could not have been reasonably anticipated, as the conduct of the case was wrong in principle. In the solitary success among the operations for aneurism, the carotid and the vertebral were also tied, and recurrent haemorrhage was controlled. In cases of punctured or gunshot wounds of the distal portion of the innominata, in which the bleeding has been temporarily controlled by compression, — such cases are recorded on page 520 and one in Dr. Blackman’s practice, in which bleeding from a small puncture was restrained by digital compression for nearly a week, — I conceive that the correct operation theoretically would be to place a ligature around the middle of the brachio-cephalic, to tie the carotid and subclavian as near the bifurcation as practica- ble, and then to amputate the arm at the shoulder. In view of the discouraging statistics of ligations of the innominata for disease, such a proposal may be regarded as preposterous, but it must be remembered that we have experience of only one ligation of the innominata for traumatic cause, and that performed under hopeless circumstance;^ that Mott and his successors, who failed in their operations on the brachio-cephalic, were not shaken in their convictions that the measure would ultimately be established as a means of preserving ^The operators, dates of operation, and duration of sui^Tval were : l^Iott, in 1818, 26 days; Graefe, in 1822, 67 days ; Norman, in 1824, GO hours ; Arendt, in 1330, 8 days ; Bland, in 1832, 8 days ; Hall, in 1833, 3 days , Dupnytren’s Parisian colleague, in 1834, — days ; Lizars, in 1837, 21 days ; Hutin, in 1842, 12 hours; Cooper, in 1859, 9 days; Cooper, in 1860, 34 days; Pirogoff, about the same time [Grundzuye (hr AUgemeinen Krieyschiruryie, Leipzig, 1864, p. 459], 24 hours; Gore, in 18(1-, 17 days; Smyth, in 1864, recovery. In four cases the artery was exposed but not ligated because of the diseased condition of its coats, namely; by Porter, in 1831 (Dublin Jour., 1832, Vol.); by Key, in 1832, deatli on the 23d day (ClilSP, On Diseases of the Blood-vessels, p. 206); by A. Post, and by Hoffman. TIic brachio-cephalic artery is said to have been tied twice by Bujalsky (Tahuhe anatomico- chirurgicse ligandarum arteriarum majorum erponentes, St. Petersburg, Elephant Folio, 32 pp. 14 pi.) I cannot refer to the magnificent work of the latter in which the cases are said to be recorded. Its companion, Operationes lithotomiie exponentes, is in the Office libraiy'. presume no one will question, at this date, that Hutin should have attempted to place doable ligatures at the scat of puncture in the axillary^ and, failing in this, to have amputated the arm. (J8 538 WOUNDS AND INJURIES OF THE CHEST. [Cmvp. V, life, and that the solitary success achieved by Smyth was attained by the removal of the sources of recurrent hoemorrhage. The operation suggested would not be more formidable, so far as the apprehension of shock is concerned, than the ablation of the arm with the scapula, or with the clavicle, operations that have been successfully accomplished for tumors of those bones. In a lean patient, if the bleeding could be staunched long enough to pass a ligature about the brachio-cephalic, the remaining steps of the operation would present no very serious difficulties. As, in a wound of the distal portion of the innominata, the probability that the application of a single ligature near the cardiac extremity would be futile amounts almost to a certainty, I believe that the measure suggested offers the sole forlorn alternative from the otherwise inevitable doom. Ligations of the Subclavian. — There were five recoveries among the twenty-five ligations of the subclavian. These five cases will be reported in the order of the length of interval between the dates of injury and of the ligation. The operations were performed on account of primary hsemorrhage in one instance, twice for intermediary haemorrhage from the axillary or one of its principal branches, once for false diffused aneurism and once for false consecutive aneurism. Three of the operations were on the left and two on the right side. Partial paralysis of the corresponding arm remained in three cases. In all five, the vessel was tied above the clavicle, near the acromial margin of the anterior scalenus. The patients were from twenty to twenty-eight years of age : Case 1. — Corj)oral G. M. Caughtian, Co. K, 13th South Carolina Regiment, aged 25 years, was wounded July 3d, 1863, the hall passing through the upper part of the chest, wounding the lung and the subclavian artery where it passes between the clavicle and the first rib. The subclavian was ligated on the inner side of the clavicle. The oper.ation was successful; the patient was furloughed, with the wounds entirely healed, but with the left arm paralyzed, one of the nerves of the brachial plexus having probably been included in the ligature. The case is reported by Surgeon H. L. Thomas, P. A. C. S.' Case 2. — Corporal D.avis J. Palmer, Co. C, 8th Iowa Volunteers, aged 20 years, received a gunshot wound of left axilla at Shiloh, Tennessee, April 7th, 1882, the ball entering two inches below the clavicle, traversing pectoralis major muscle and lodging near scapula, after wounding the axillary artery ; hemorrhage occurred on April 8th. He was admitted to Floating Hospital Empress, on April 14th, and on the same d.ay a tumor three inches in diameter, pulsating with an aneurismal thrill, bleeding when pressure on subclavian was removed, was ligated. An incision from the clavicular origin of the sterno-cleido- mastoid to near the border of the trapezius was made, the border of the scalenus anticus was found, and the left subclavian w'as ligated, with the gre.ater portion of its sheath, chloroform having been administered. The condition of patient at time of operation was anaemic. Bottles of hot water were applied to relie.ve the excessive numbness of the left arm, and nourishing diet was given. He w'as transferred to general hospital at Kex)kuk, Iowa, April 20th, 1882. The ligature came away on May 20th, thirty-six days after the operation, and he was furloughed on M.ay 29th, 1882. He was discharged the service on September 6th, 1862. He was, on June 16th, 1863, mustered in as captain, Co. A, 25th Iowa Volunteers, and mustered out as lieutenant-colonel on June 6th, 1865. The case is reported by the operator. Surgeon Thomas F. Azpell, U. S. V. Examining Surgeon William McClelland, Washington, Iow.a, reports, M. V, Case iscles much contracted in their movements; the arm cannot be thrown from the side at a greater angle than ten degrees. The disqualification for manual labor is entire and permanent in that degree.” ■Desault, Journal de Chirurgie, Paris, 1771. ^Zano, C. 15., Darslellung blutiger heilkunstlerischer Operationen, Wien, 182:3, Theil I, S. 2:5:5. *X6L.vrox, £le7n. de Path. Chir., T. Ill, p. 4.>2. The instniracnts of this description desi/jned fi r tlie treatment of ci)istaxi3 or the dilatation of the uterine canal are fragile and unreliable. The materials for Desault s tampon are always at hand, and the compress can bo made strong and safe. If tho attempt to ligate the vessel fails, this is tlie best resource. The hazard of exciting inllummation in the iiloiira and lung is less to be dreaded tlian tlio danger of hsemothorax. It is approved by Velpeau {op. cit., T. II, p. 2(17). 550 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, Ligations of the Intercostal Artery. — Seven cases of gunsliot wounds of this vessel have been reported, on page 526, et seq. In the eight following cases of the same nature, attempts were made to control the bleeding by ligature; but six of the eight cases resulted fatally. In the first, the old method of Gdrard,^ of including the rib, nerve, and veins in the ligature was adopted: Case. — Private Smith Scofield, Co. D, Gth Connecticut Volunteers, aged 21 years, was wounded at Drury’s Bluff, Virginia, May 14th, 1864, by a round ball, which enttneil the right side of the chest, just posterior to the angle of the ninth rib, passed anteriorly, fractured the ninth and tenth ribs, and emerged about three inches anterior to angle of tenth rib. He was treated in the field, and, on the 19th, sent to the hospital at I’oint Lookout, Maryland. On May 27th, profuse haemorrhage from both wounds occurred, which was only controlled by cutting down and joining the wounds of entrance and exit in the track of the ball, and ligating the tenth intercostal artery bypassing a ligature around both vessel and rib. The operation was performed by Assistant Surgeon William H. Gardner, U. S. A. Cold-water dressings were ajiplied. The haemorrhage did not recur. The patient was transfe'rred, on September 3d, 1864, to Connecticut for muster out of service. Examining Surgeon G. B. Upham, of Yonkers, New York. July 8th, 1867, reports ; “ The wound of side consists in having portions of three ribs removed by a musket ball, leaving the right side much impaired so far as the action of the lung is concerned. The injury to the arm consists in having the upper portion of the right arm impaired from the effects of the same wound in the right side. The two wounds incapacitate the applicant one-half and ))ermanently.” One great objection to tlie use of styptics in tliis class of wounds is the clanger of their falling into the pleural cavity, and the emphtyment of powdered substances would be especially exposed to this hazard. Probably the opening into the chest was obstructed, in Dr. Duer’s case, by coagula or sloughs. At all events, the result was successful: Case. — Private Reuben Morris, Co. K, 142d Pennsylvania Volunteers, aged 2.5 years, received a gunshot wound of the left side, between the tenth and eleventh ribs, at Fredericksburg, Virginia, December 12th, 1862. He was treated in the field ami was transferred to Finley Hospital, Washington, on the 24th, and to Convalescent Hospital, Philadelphia, on January 11th, 1863. On January 20th, secondary hmmorrhage occurred from the intercostal artery to the amount of four ounces. Acting Assistant Surgeon Edward L. Duer, tied the artery at one extremity in the wound ; the hatmorrhage did not recur. After the ligation the wound was filled with subnitrate of bismuth and a compress applied. This dressing was allowed to remain seventy- two hours, when the slough came away with the dressing and the sore presented a perfectly healthy appearance. He \vas discharged from service June 13th, 1833. The case is rejxjrted by Assistant Surgeon V. B. Hubbard, U. S. A. Examining Surgeon Charles Mace, of Scranton, Luzerne County, Pennsylvania, reported, June 22d, 1863: “Morris was wounded through his left side, fracturing two ribs. Disability one-half.” He was last paid on March 3d, 1872. In the next case, the attempt to tie the vessel was unsuccessful, tbougli undertaken by an experienced medical officer. Surgeon T. Antisell, U. S. V.: Case. — Private Alfred McClay, Co. E, ll4th Pennsylvania Volunteers, aged 17 years, was wounded at Fredericksburg, Virginia, December 13th, 1862, by a conoidal ball, which entered the right side at the costal cartilage, and emerged at the angle of the ninth rib, fracturing the lil) between the point of entrance and exit. He was treated in the field, and, on December 17th, was sent to Harew'ood Hos])ital. When admitted, he suffered from traumatic pneumonia, which was treated by venesection and the administration of morphia and antimony. He recovered sufficiently to be able to move about the ward. The wound healed kindly. On January llth, a profuse htemorrhage occurred from the wound, probably from intercostal artery, which continued in spite of compression. An unsuccessful attempt was made to ligate the artery. The htcmorrhage was finally suppressed, after an alarming loss of blood, by tight bandaging and styptics. The stoppage of tlie haBinorrhage was immediately followed by pain on both sides, cough, and expectoration. Pyatmia set in, and death occurred on January 24th, 1863. Necropsy : No opening had been made into the cavities, either by the missile or ulceration. Eight abscesses, from the size of a pea to that of an orange, were found in the lower lobe of the left lung, which was also in a ver}' congested condition. Case. — Private J. B. Bruce, Co. C, 31st Alabama Regiment, aged 17 years, was wounded in the chest by a minio ball and taken prisoner at the battle of Shiloh, April 6th, 1862. Assistant Surgeon B. Howard, U. S. A., in a report of the case published in The American Medical Times, Vol. VI, page 52, says: “ My attention was specially called to his case the second day out from Pittsburg Lauding by my friend Dr. Busli, sr., of Lexington, Kentucky, because, of the many cases of wounds of the chest on board the transport, this was one of the very few in which the ball had lodged. The patient had a rather favorable appearance, and the wound looked well, with no tendency to hatmorrhage. April 17th, patient was admitted to General Hospital, Louisville, Kentucky, with gunshot wound of the chest, fracturing the ninth rib about three inches to the left of the spinal column. The usual symptoms of gunshot wound of the lung which were present gradually disappeared ; the hectic which ensued had ceased, and the patient, though very weak, was convalescing with remarkable rapidity ; medication had been discon- tinued, the only remaining treatment consisting in the use of simple dressing and bandage to the healing wound. April 29th : Galling accidentally at the hospital at about one o’clock P. M., 1 was informed an orderly had been dispatched to request me to visit the patient immediately. Secondary hasmorrhage had suddeidy occurred, the bed was already saturated with blood, and the patient almost in a state of syncope. A medical officer had been trying in vain to stop the bleeding for about half an hour, and when I ‘(ff:uAUI), in Dionis, Cours d' Operations de, Ctiirurpie, e. II. S. 210) passed a riband by a flat flexible probe througli a new opening made in the intercostal space above. Steidele {Ahhandlung von den BIu{/tilssen, Wien, 1776, S. 77) proposed to substitute a silver probe cur\’ed in S, and BoriCiiEit {Audi cine Compressions- meihodef. d. Arteria intercostalis, in dessen Ahhandlung v. d. Krankheitcn der Knochen, Leipsig, 1795, S. 233) proposed a bent bulbous steel probe with an eyelet. Reich (VELPEAU, Nouv. £lem. de Med., Op. T. II. p. 265) advised that both ends cf the ligature should be passed through a piece of gum catheter before knotting. If, with the aid of these suggestions, the operator succeeds in ligating the intercostal with the rib, he may contemplate with Sabatier {De la Mcdecinc Operatoirc, 6d. dc Sanson et Begin, 1812, Tk II) the dangers of iiuncturing the pleura, of necrosis from denudation of the rib, and of the pledget or tent falling into the pleural cavity. The plans for tying the artery above, or the artery, vein, and nerve together are also numerous. Reybard {Mem. &ur le Traifement des Plaits Penetrantes de la Poitrine, Paris, 1827, p. SCO) and Nevermann {Ueber das heste Verfahren, cim Hsemorrhagie der Art, intercostalis nach Verwundungen zu stillen, in Berliner IMed. Centralzeitung, Ang. 6, 1836) propose to use sttiphyloraphic or other jointed needles to pass the thread; Grossiiedi ( V. Graefe nnd V. Walthcr's Jour.) recommends Arendt’s aneurism needle, which Chelius {Ueber das Verletzung der arteria intercostalis in gerichtlich Medicinischer Ilinsicht in Heidelb. Klin. Annalen B. Ill, H. 2) condemns. B. Bell {A System of Surgery, 7th ed., 1804, Vol. 1, p. 258) insists that in thin people, it is always practicable to expose the vessel and to take it up with a sharply curved tenaculum. This failing, he would resort to I^eber’s plan. Assalini {Manuals di Ckirurgia, p. 57) advises that the artery be cut across and allowed to retract, and ThedEN ( Willd. vernwundete Arteria intercostalis ganz durchschneideii und zurilcl'schieben ; dessen neue Bemerk. und Erfabr. Th. I, Berlin, 1782, S. 59) contends that bleeding may always be stanched by ccrnplcting the division of the artery, turning back its posterior extremitj’-, and plugging the wound. GutiIRIE {Commentaries, L c. p. 519) met with no difliculty in using torsion in one case, and the ordinary ligature in another. BILGUKU (Pract. Anweizung fiir Fcldwunddrzte, Berlin, 1783, S.118) and lllCHTER {Chirurgischc Bibliothch, Gottingen, B. IV. S. C95) applauded the plan of tying a stout thread about the middle of a tent, introducing the latter horizontally through the wound, which is enlarged if necessary, then placing the tent vertically and drawing upon the chord, thus compressing the artery, and the edges of the two adjacent ribs as well, as Velpeau remarks. Lotieri, of Turin {Ilistoire de V Academic royalc dc Chirurgie, p. XCV, appended to the second volume of the Memoirs of the Academy, 4"^, Paris, 1753), invented a steel plate, with a pad and perforations at the ends for passing a riband, and proposed to introduce this instrument within the chest to make direct compression on the artery. Quesxay (in Sabatier. 1. c., p. 84) substituted an ivory whist-marker, with a dossil of lint for a pad, and perforations for a tape to. keep the instrument in place. BELLOQ {Mem. dc CAcad. de Chir. T. II, p. 121, Plate IV) found all their plans defective and invented a complicated tourniquet or vice with steel convex disks, between which the rib and its vessels were to be compressed. The employment of these machines involved the necessity of a very large wound in the chest. Digital compression by relays of assistants has found its advocates (according to VELPEAU, 1 . c., p. 2GG). LOEFELER {Blutsiillung aus d. Arteria intercostalis, in Blumcnbach's IMed. Bibliothek, B. Ill, S. 511, Gottingen, 1794) teaches that the intercostal space should be opened and the artery tied posteriorly to the wound, leaving the latter open for the discharge of blood and secretions. I^rofessor GROSS, {Op. cit., 5th ed., Vol. ir, p. 444) proposes to drill a small aperture into the rib, immediately above the artery, and to pass a silver wire around its bleeding orifice. CHET.irs {South's Translation, Am. ed., 1. c., T. J, p. 492) well observes that bleeding from the interccstal arterj'' is often obsei^’ed by the military surgeon in connection with laceralifin of the lung, and that most <.f the methods above mentioned increase the bleeding from that organ. AVhen the intercostal artery is wounded between the sternum and angles of the ribs, where the majority, perhaps, of wounds of the chest occur, the vessel does not always bleed freely; hut posteriorly a wound almost iiivariably causes profuse bl(‘(Mling. ami liore the vessel is secured to be such. On the extraction of the cloth, haemorrhage per saltum commenced, which, however, was easily controlhal by pressure on the subclavian above the clavicle by means of a door-key. The patient only survived the 70 Fig. 2r;3. — Portion of riglit axillary artcr^', its coats ulcerated throngli, after ^ainshot contusion. Sect. I, A. M. M. 554 WOUNDS AND IN.JUETES OF THE CHEST. [ClIAP. V, operation a few niiimtes. Necropsy : A largo semi-circular portion of the axillary artery, correspoiidiiig to about half the calibre of the vessel, was clearly cut out by the ball, about au inch below where it is called the subclavian. The bone and brachial plexus were uninjured. The lower dissection showed the fractured rib, with suppurating soft parts, corresponding to the course of the ball. The most important fact connected with the case was the great length of time before intermediary lueiuorrhage took ])lace — nine days. There is no doubt th.at the cloth was driven into the iirtery, and, possibly, by some movement of the patient afterward, or from suppuration of surrounding tissues, this and the coagula were dislodged. Almost invariably such a wound iu an artery of this calibre would cause death in less th.an five minutes. The w'ood-cut (FiG. 253) on the preceding page represents a preparation of the axillary artery. It was contributed, with a history of the case, by Assistant Surgeon H. J. Phillips, U. S. A. Case 5. — Private John W. Hills, Co. A, 145th Pennsylvania Volunteers, aged 24 years, was wounded at Fredericksburg, Virginia, December 13th, 1862 ; the ball entered the integuments at the middle third, external edge of the scapula, passed through the axilla, and lodged in front, just below the insertion of the pectoralis minor. He was carried to the field hospital, where the ball was removed a few hours after the reception of the injury. Simple dressings were applied. On the 17th, he was transferred to Harewood Hospital, Washington. The case progressed well until the 23d, when haemorrhage to the amount of about six ounces occurred from the posterior wound. The wound was enlarged and the bleeding vessel searched for, but it could not be found, although it was supposed to be the suprascajiular artery, as pressure below the clavicle arrested the haemori'hage. The edge of the scapula was denuded and rough for .about one inch. The axillary artery was ligated immediately after its emergence from beneath the clavicle and the incision brought together by adhesive strips. December 24th : Some febrile disturbance. A diaphoretic was administered, and milk diet ordered. 25th: Nervous delirium ; stimulants, with morphia, beef tea and chicken diet. 26th: The delirium has subsided. On the 27th, he refused to take the stimulants and morphia, and the delirium returned. It was with the greatest difficulty that nourishment could bo administered to him, as he closed his teeth and rejected everything. He continued in this condition until the 29th, when a capillary haemorrhage occurred to the amount of about one ounce from the posterior wound. Compress and bandage were applied, which entirely arrested it. He would occasionally take a spoonful of milk punch with a small quantity of morphia in it. Death resulted on the night of December 29th, 1862. The ligatures h.ad not come away. The wound of incision had suppurated freely but there was no attempt at union. Surgeon Thomas Antisell, U. S. V., reports the case. Case 6. — Serge.ant John Mackey, Co. I, 50th Pennsylv.ania Volunteers, aged 23 years, was admitted to Mount Pleasant Hospital, Washington, May 29th, 1864, with a gunshot wound received at Cold Harbor, Virginia, on the 25th. The ball entered .at the anterior aspect of left arm and made its exit at posterior and inferior border of scapula; the a.xillary artery was divided about where it becomes the brachial. June 5th : Arm and forearm immensely swollen from erysipelas and extravasation, and in a sloughing condition. The patient was nearly exhausted from excessive haemorrhage from the axillary artery. Acting Assistant Surgeon H. Craft attempted to ligaV; the axillary artery. An incision of three inches was made along the border of the dorsal muscles, and the .artery exposed. While in the .act of taking it up the patient died. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. Case 7. — Private John Moser, Co. B, 51st Illinois Volunteers, aged 18 years, was wounded at Franklin, Tennessee, November 30th, 1864. A conoidal ball entered over the anterior border of the right scapula, fractured the bone, passed downward, and emerged at lower angle of scapula. He was admitted on the next day to Hospital No. 3. Nashville. Tonics and nourishing diet were administered. On December 12th, intermediary haemorrhage occurred ti’om enlarged vessels of the collateral circulation ; pressure was applied and the bleeding arrested until the 14th, when it again occui-red. A ligature was now successfully applied to the axillary artery under the border of the pectoralis minor muscle. This arrested the bleeding until the 19th, when profuse haemorrhage occurred from the incision. The wound was plugged.with lint saturated with tincture of iron and pressure was applied. The haemorrhage did not recur, but the patient failed to recuperate, and died December 21st, 1884, from exhaustion. The case is reported by Surgeon J. R. Ludlow, U. S. V. Ca.se 8. — Private Asahel A , Co. F, 25th Massachusetts Vtdunteers, aged 25 years, was wounded at Cold Harbor, Virginia, June 3d, 1864; a conoid.al ball entered the left .axilla and lodged at the posterior border of the scapula. He was taken to the field hospital of the 2d division. Eighteenth Corps, where tlie ball was removed and simple dressings were applied. On June 11th, he was transferred to Lincoln Hospital, Washington. On the 15th, intermediary haemorrhage to the amount of about twenty ounces occurred, probably from some branch of the axillary artery. The wound was dilated .and a small artery, probably one cut in dilating the wound, ligated. The wound was filled with lint saturated in a solution of persulphate of iron, and a compress applied. The .axillary artery could be distinctly felt with the finger, pulsating in the wound. Pulse regul.ar, but weak; patient looked pale. Anodynes and stimul.ants were administered. On the next day hmmorrhage again occurred, which yielded to strong pressure on the compress. June 17th, 10 A. M. : Patient very pale, amemic, and suffering from much pain in the arms .and shoulder. The compress and plugging were removed, when the blood gushed out .alarmingly. The wound was freely dilated and the axillary artery ligated. The haemorrhage stopped and at the same time the heart ceased to beat. The necropsy showed the axillary largely opened .about the middle of its course, on the side next to the track of the ball. There had evidently been sloughing through nearly the whole calibre ol the artery. The adjacent wood-cut (Fig. 254) represents a preparation of the left axillary artery, with a large and deep ulceration, involving nearly half of the cylinder of the vessel, about an inch above the origin of the subscapularis. It was T.,.. c^rA -n c 1 a. . 1 ■ , ... contributed, with a history of the case, by Acting Assistant Fig. 254. — Portion of a left axillarj- artery, showing an ulceration after ’ •' > J o ligation. .Spec. 257(), .Sect. I, A. M. M. Surgeon W. L. Herriman. Sect. III.] LIGATIONS OF THE AXILLAEY. 555 ('.\SE9. — Private James T. Sliephord, Co. A. 18th Massachusetts Volunteers, aged 18 year.s, of a naturally strong and vigorous constitution, was wounded at Gettysburg, Pennsylvania, July 2d, 183d; the ball entered at the inner edge of the dcd- toid of the left side, at the curve of the armjiit. passed through the axillary space, and emerged three inches below on the outer side of the arm ; a great (piantity of blood was lost at the time of the injury. lie was treated in the field until the 8th, when he was transferiH'd to S.'itterlee Hospital, Philadelphia. The patient was kept as fjuiet as possible, and cold water aii](li(M to the wound. On the 14th, arterial hajmorrhage took place, when about a pint of blood was lost. The wound was immediately cut down upon, and the bleeding vessel, supposed to bo the axillary artery, was tied. On the 19th, hasmorrhage to the amount of about eighteen ounces occurred ; the wound was again opened and the vessel secured higher up. On the 23d, hfemorrhago re- curred again, and the vessel was ligated still higher up. It was only after the third ligation that the pulsation at the wrist was stopped; during the intervals of the haemorrhage he was kejit up with beef tea, brandy, milk, etc. After the third hemorrhage he was excessively exhausted, and it seemed as if he would hardly rally. A fourth haemorrhage, on July 24th, caused deatli. The case is reported hy Acting Assistant Surgeon T. G. Morton. Case 10. — Private David Walsh, Co. D, lOGth New York Volunteers, aged 23 years, was admitted to Filbert Street Hos- pital, October 24th, 18G4, with a gunshot wound of the left shoulder, received at Cedar Creek, Virginia, on the 19th. November 3d : Vessels and tissues much matted together. The patient’s constitutional condition, which was good primarily, was greatly i-educed by haemorrhage. Acting Assistant Surgeon Edward L. Duer administered chloroform and ethei-, and ligated the left axillary artery immediately under the clavicle, in the triangle formed by the pectoralis minor muscle, thorax, and clavicle. Un- der the free use of cream, butter, and wines the progress of the case was very encouraging, but haemorrhage recurred on No- vember loth; death resulted on the .same day. Surgeon Thomas B. Eeed, U. S. V., reports the case. Case 11. — Private Charles Tighe, Co. F, both Massachusetts Volunteers, aged 18 years, received a gunshot wound of the left chest and arm at Petersburg, Virginia, June 16th, 1834. The ball entered at the middle of the pectoralis major of right side, passed through the left axilla, and emerged at the upper third of the arm, outer aspect, wounding the axillary artery. He was at once admitted to the hospital of the 1st division, Nintli Corps, where simple dressings were applied to the wound. On the 19th, ho was transferred to Harewood Hospital, Washington. On July 1st, intermediary hmmorrliage to the amount of twelve ounces occurred, and on the next day Surgeon R. B. Bontecou, U. S. V., ligated the axillary artery. The htemorrhage did not recur, but the patient died July 4th, 1864, from exhaustion. The case is reported by the operator. Case 12. — Private William E. Downing, Co. 1, 16th Pennsylvania Cavalry, aged 19 years, was wounded at Hanover, Vir- ginia, on May 28th, 1864, by a conoidal ball, which passed through the left axillary space. Flo was conveyed to the field hospital of the '^d division. Cavalry Corps, where the wound was dressed. On June 4th, he was transferred to De Camp Hospital. New York Harbor. On the l-.ith, intermediary haemorrhage to the amount of twenty ounces occurred from the axillaiy artery. On the 15th, the patient was jnit under the influence of chloroform and the axillary artery was ligated above and below the wound. The vein was found injured, and was also ligated. The haemorrhage did not recur. Death ensued on June 28th, 1834. Assistant Surgeon Warren Webster, U. S. A., reports the ca.se. There was no evidence at the post mort'-m, examination of the phlebitis or of pyaemia. Case 13. — Private E. C. Melley, Co. K, 2d West Y'irgiuia Jilounted Infantry, was wounded at Droop Mountain, Virginia, November Gth, 1833, by a musket ball, which entered one and one-fourth inches below the junction of the inner and middle thirds of the clavicle, passed downward and backward, and made its exit about midway of the inferior costa of the scajmla, one-half an inch from its edge. He was conveyed to Beverly, and admitted, on the 12th, to the post hospital. Simple dressings were applied to the wound. On the 18th, he was transferred to Grafton, a distance of forty-six miles. When admitted, an enormous tumor of coagulum occupied the a.xilla, burrowing under and between the pectoral muscles as well as the scapula and latissinius dorsi, filling up the space below the clavicle, and rendering all the tissues tense. The superficial veins were enlarged. The patient had lost considerable blood while being removed from Beverly. He i)assed the night tolerably well. Pulse quite full at both wrists. The hmmorrhage proceeded from the anterior orifice; the posterior one was closed and nearly healed. On Novem- ber 19th, Surgeon S. N. Sherman, U. S. V., administered chloroform and ligated the axillary artery over the second rib. An incision was made along the junction of the sternal and clavicular portion of the pectoral muscle, and the clot turned out, when a sudden and tremendous gush of blood took place, wdiich was promptly arrested by compression above the clavicle. The clav- icular portion of the muscle was partly divided at right angles to the first incision. The depth of the wound was considerable, rendered so by the swollen condition of the parts ; the tissues were greatly disorganized. Pulsation of the artery was arrest(>d by compression above the clavicle. In searching for the art('ry the subclavian vein was opened, the entrance of air caused syn- cope, and death ensued in from seven to ten minutes. The necropsy revealed the axillary artery almost entirely divided about one inch before it becomes the brachial. The case is reported by the operator. Of the thirteen foregoing operations for ligation of the axillary, there were four of what is called diffused aneurism ; which, as Professor Gross remarks, is not an aneurism at all. Yet in these cases the compression exercised by the effused blood and, in two of them at least, injury of the brachial plexus and axillary vein, had so seriously interrupted the circulation of the arm, that it is highly probable that amputation at the shoulder-joint, or the “ old operation,” might have given less disastrous results, or at least would have been more correct practice. Of Case 3, Surgeon 0. S. Frink remarks : “ The patient was not in a favorable condition. The arm was cold, and jferfectly paralyzed; at onetime there was a slight movement of the fingers possible, but this was soon gone, and although 556 WOUNDS AND IN.IUKIES OF THE CHE^ST. [Chap. V, there was no diroet injury of the axillary plexns, sensation and motion were not restored after the artery was ligated, owing to the fact, as I think, of the collateral circulation being impeded by the pressure of the aneurism, prior to the operation, and there not being sufficient vigor in the system to restore it afterward.’’ — {Medical Director H. S. Hewit’s Report, p. 81.) In one of these four cases, the promptly fatal issue was referred to entrance of air into the subclavian vein. In one, gangrene appeared, and two were fatal from anaemic exhaustion before mortification set in. Of the nine remaining cases, six, in which single ligatures had been placed on the cardiac side of the wound, died of recurrent distal haemorrhage;* two were so , exhausted that they died during the operation; while Dr. Webster’s patient (Case 12) lived till the thirteenth day, and appears to have succumbed to the prostration consequent on the bleeding prior to the operation. In this case and Dr. Shippen’s (Case 3) alone of the thirteen, was the artery tied below as well as above the wound. In ten of the thirteen cases, the missile injured the axillary artery ; in three, bleeding was thought to proceed from the thoracic, scapular, or circumflex branches. That pressure below the clavicle should arrest hsemorrhage from the suprascapular (Case 5) was singular, to say the least, and led to practice, which, unless the bleeding in Case 7 came from another branch of the subclavian, the posterior scapula, is believed to be unparalleled. Though one or two of the operations may be regarded almost as ligations of the subclavian toward the end of its third portion, the error of tying that vessel above the clavicle for wound of the axillary [see Guthrie, Lect. XII, p. 200) was not committed in any of the cases of this lamentable series. Ligations of Branches of the Axillary. — In wounds of the chest complicated by bleeding in the axilla, after the main trunk, the subscapular was the vessel most com- monly injured. But no instance appears of ligation of this trunk in the continuity for wounds or for wounds of its branches, though it was not infrequently tied in operations for amputation. The Museum affords a specimen, represented in the wood-cut (Fig. 255), of a gunshot wound of this vessel, resulting in sloughing and fatal secondary hgemorrhage : Case. — Private F. M. Drale, Co. D, 35th North Carolina Regiment, aged 27 years, was struck by a musket ball, at Petersburg, June 16th, 1864, three inches below the left clavicle. The missile made its exit at the posterior border of the left axilla. He was made a prisoner, and sent to Lincoln Hospital on June 25th. He had full extra diet and simple dressings, and nothing of importance occurred until July 10th, when there was profuse arterial bleeding from the exit orifice, stanched by plugging the track of the ball with pledgets of charpie dipped in solution of persulphate of iron, and applying compresses tightly bandaged in the armpit. Bleeding recurred, and the patient died on July 12th, 1864. The post-mortem dissection revealed a phagedenic condition of the posterior part of the wound, and the subscapular artery was com- pletely sloughed through at its origin. The specimen was contributed by Acting Assistant Surgeon II. M. Dean ; the notes of the case by Acting Assistant Surgeon Thaddeus L. Leavitt. Case. — Private Daniel Hughes, Co. Iv, 13th New York Artillery, aged 23 years, was admitted to the Foster Hospital, New Berne, North Carolina, with an incised and punctured wound of the left side and hip, inflicted with a knife at New Berne on the same day. On admission, there was hmmorrhage from the thoracica longa artery. The patient’s condition was good. Assistant Surgeon E. F. Hendricks, 15th Connecticut Volunteers, ligated the bleeding vessel ; simple dressings were applied. He recovered and was returned to duty September 27th, 1864. The case is reported by the operator. Case. — Private Zeba S. Lyon, Co. I, 17th Vermont Volunteers, aged 20 years, was wounded at Petersburg, Virginia, April 2d, 1865, by a conoidal ball, which fractured the middle and anterior border of the right scapula and the fourth rib, passed into the lower lobe of the right lung, and lodged. He was taken to the field hospital of the Ninth Corps, and, on April 0th, was transferred to Slough Hospital, Alexandria. Light cold-water dressings and stimulants were used until April 14th, when Theodor Bilrotli would, perhap.s, contest the distal origin of the fatal haemorrhages in some of these cases. .See the fifteenth letter of his recent Chirurgisdte Bnefc. liut I think the prcpariitions in the Museum would convince him of the frequency of bleedin/j of this nature. sloughing off of the subscapular at its origin. Spec. 2833, Sect. I, A. M. M. f r.cT. III.] EXCISIONS OF THE CLAVICLE. 557 liaeniorrliage occurred from a small branch of the circumflex artery, which was ligated at the time. Oil the Kith, hamiorrhage recurred from a deeper branch. Several minor branches of the circumflex artery were cut down upon and ligated by Surgeon Edwin Bentley, U. S. V. The patient lost in all about twenty ounces of blood. Nourishment and stimulants were administered. Death resulted on April 21st, 1835. The necropsy revealed the course of the ball. The lower lobe of the right lung had under- gone decomposition ; the upper lobe was congested. Doubtless many branches of the thoracic and scapular arteries were occasionally tied to arrest primary or secondary bleeding from wounds, or else in the course of operations; but special references to such instances do not appear on the reports. This review of the results of ligations in the trunk, after gunshot wounds, is very discouraging, and it can hardly be denied that the excessive mortality was, in a measure, due to departures from accepted rules of practice. But the difficulties in dealing with gunshot wounds of the clavicular and axillary regions are so great, as often to defy the best planned and most skilfully executed surgical interference; and those whose experience of traumatic lesions of the subclavian and axillary regions is largest, are least hasty in criticising failures in their management.* Excisions. — Though excisions of the bones of the trunk, and possibly those of the joints, have been known and practiced from early times, from the time of Galen indeed, it is little more than a century since they have been reintroduced and practised according to fixed rules as belonging to the established resources of surgery. Until the publication of Park’s two letters, in Jeffray’s translation of Moreau, in 1806, and Syme’s work, in 1831, the English language possessed no book on excisions, and yet, in 1803, the Moreaus had excised nearly all of the larger joints. Excisions of the Clavicle. — Extirpation of the collar-bone on account of necrosis, or for malignant growths, may be regarded as an established operation of recent date.*|* Though rarely required in gunshot fractures of the clavicle, in very extensive comminutions the complete excision of the bone may possibly be expedient. It was twice, at least, resorted to during the war ; on both occasions with a fatal result. The first case is accredited to a Confederate surgeon, whose name is not given, at the battle of Spottsyl- vania. The memorandum of the operation appears on the monthly report, for May, 1864, of Surgeon J. L. Cabell, the professor of surgery at the University of Virginia : Case 1. — Private Henry Miller, Co. I, 5th Virginia Eegiment, was admitted to the Confederate hospital at Charlottesville, Virginia, May 8th, 1864, with a gunshot wound of the chest and fracture of the clavicle. The clavicle had been excised on the field, on the 6th. He died on May 17th, 1834. The case is reported by Surgeon J. L. Cabell, P. A. C. _S. * For a fatal case of ligation of the left subclavian in the second portion, for gunshot wound of the axillary, see Military Surgery and Operations following the Battle of lUvas^ Nicaragua, April, 18.56, by I. MOSES, M. D., late Surg6on General of the Nicaraguan Army. Ilosides the authors already cited, consult, on this subject: NO'IT, J. C., Ligature of Subclavian Artery for the cure of Axillary Aneurism caused by Gunshot wouml, Am. Jour. Med. Sci., p. Ill, Vol. II, 1841 ; Sir Willi.vm FeroussOX’s remarks in the last edition of his System of Practical Surgery, London, 1870, and in the later volumes of the lancet ; Mr. J. E. Erichsen’s ohsci^-ations in the fifth edition of his Science and Art of Surgery, London, 1869, Vol. II, p. 8(i ; Mr. J. Spence’s Lectures on Surgery, Edinburgh, 1871 ; Sir James Y. Simpson's Acupressure, Edinburgh, 1864 ; Professor Gross’s learned critical and historical comments in the fifth edition of his System of Surgery, lOiiladelphia, 187i, Vol. I, p. 804, Vol. II, p. 4.50; Dr. J. Ashliurst's excellent summary of tlie present state of our information in his nevr Principles and Practice of Surgery, Philadelphia, 1871, p. 547; BILUOTII, Vhirurgische Briefe, U. S. V., Berlin, 1872, S. 113; George Fischer, in Dr. von Pitha's Uandbuch. t Professor Gross informs us {System of Surgery, Vol. II, p. 1077) that llemmcr extirpated the clavicle for osteosarcoma as far back as 1732. Dr. O. lleyfelder {Lehrhuch der Resectionem, Wien, 18C3, S. 300) has collected nine cases of total, and eighteen of partial excision of the bone, and ascribes the priority in practicing total excision to Jleyer, who operated, in 1823 {Encyc. Worterbuch de Med. TFiss., B. 29), successfully on a man of 34 years, witli caries; hut he ascribes a partial resection of the diaphysis to ('assebohm, in 1719 {Act. Med. Berol., B. I). In 1813, Dr. Charles lUcCreary, of Kentucky, excised tlic right collar bone, of a boy of 14 year.s, for scrofulous caries. The boy survived many years, with an excellent use of the C/Orresponding limb. The specimen is in Professor Gr.iss's private collection. Drs. Wedderhurn, of New Orleans, in 1852; Blackman, in IS.IG, and Finpia, of Richmond, in 1860, had like success in similar cases. Moll, in 1828; J. (k Warren, in 1832, and Dr. E. S. (jooper, in 18.57; Dr. Curtis, of Chicago, about the same year, and Dr. Eve, of Xashvillc, in 1870, performed the operation for malignant tumors. Mott's ease alone was successful. For the removal of tumors, the operation is of course far more difficult than in caries; Mott applied over forty ligatures in the course of his operation, which lasted nearly four hours. 558 WOUNTJS AND INJURIES OF THE CHEST. [Chap. V, Of the next operation of this nature, more particulars are furnished. The operator was Dr. James 0. Palmer, now Surgeon General, U. S. N. : Case ‘2. — Peter Pitts, a landsman of the United States Ship Hartford, aged 19 years, received a penetrating wound of the chest in action at Mobile Ray, August 5th, 1834. In a communication to the American Journal of Medical Sciences for April, 1835, Passed Assistant Surgeon J. K. Tryon, U. S. N., says : “ The patient was supposed to have been wounded by a fragment of shell, which entered midway between the articulations of the clavicle of the right side, splintered the hone to both sternal and acro- mial e.Ktreraities, fractured the first two ribs near sterno-costal articulation, passed through the apex of the right lung, and made its exit through the scapula just beneath the spine of that bone. The wound of entrance was oval, edges jagged and inverted, with the fractured extremities of the clavicle pressing downward and inward upon the blood-vessels and nerves in that region. The wound of exit was nearly circular, edges lacerated and everted, with .spiculae of bone from the clavicle and scapula protruding. Si.x hours after the injury, the patient (being tjuieted from time to time by the inhalation of chloroform) was brought under the attention of the surgeons of the Hartford. After careful examination, finding no portion of the clavicle could be preserved. Dr. James C. Palmer, surgeon of the fleet, removed the entire hone. During the dissection, the attachments of the sterno-cleido- mastoid and trapezius to the clavicle were removed ; the external jugular was the only vessel tied. The edges of the wound were brought carefully together by the interrupted suture and water dressings applied; the spiculm of bone were removed from the wound of exit and dressed in the same manner. The patient bore transportation exceedingly well, and, on the afternoon of August Cth, when admitted into the Naval Hospital at Pensacola, symptoms were quite favorable. August 8th ; Many additional pieces of bone were removed from the wound of exit and sutures taken from the incision made by the operation. On account of the severe injury to the lung, pneumonia soon supervened, and very little hope of recovery was entertained by reason of the severity of the attack. However, on the 19th, the patient was fully convalescent from the pneumonia ; wounds looked favorable, suppurated freely, and healthy granulations were observed throughout the wound of exsection, with sternal point nearly closed. The patient continued to improve till the 22d instant, when he became anxious and restless ; bed-sores were soon developed, and, by gravitation of pus at the wound of exit, abscesses formed beneath the scapula, which exposed the entire lower border. This wound gradually assumed an unhealthy action ; patient became emaciated, and died of exhaustion at twenty minutes after seven o'clock l’. JI., August 20th, 1834, twenty-five days after the injury and operation. At the time of his death the wound of excision had entirely healed near the sternal end, and was filling up rapidly by healthy granulations near its outer extremity. With this evidence of repair we can safely state the perfect success of the operation, and but for the severe wound of the scapula the probable recovery of the patient. Treatment throughout : Tonics, stimulants and anodynes, and during the difl'erent stages of pneumonia, the usual course was pursued.” At the necropsy, on examining the thorax, about one-fifth of the upper portion of the right lung was found to have been destroyed, probably by the missile, in conjunction with the subsequent suppuration. Tliis cavity was lined with a tough memhrane three lines in thickness, dividing it from the lower portion of the lung, which was found to be perfectly healthy. Direct communication had existed between the anterior and posterior wounds. Surgeon General J. C. Palmer contributed, December 2oth, 1872, the pathological specimen from this case. Spec. 5213, Surg. Sect. It consists of the fractured right scapula, upper extremity of humerus, and first and second ribs, both of the latter fractured. Unless complicated by serious injury of tlie lung, nerves, or great vessels, it would not appear that the operation is necessarily a very fatal one. Six of nine cases of extirpa- tion of the clavicle collected by Dr. 0. Heyfelder {op. cit. 8. 300) were perfectly successful, and several other successful operations have since been reported. Partial excisions of this bone for necrosis, or compound fracture, or dislocation are more common. Some surgeons (Dr. E. C. Cooper, Assistant Surgeon Ayres, U. S. V.) practice excision of the sternal portion of the clavicle to facilitate operations on the brachio- cephalic or the first portion of the subclavian. The sternal extremity is a favorite seat of syphilitic caries, which may require gouging or partial excision. The three following cases of excision of the outer third, inner third, and middle third of the clavicle were fatal, but were complicated by gunshot perforations of the lung; Case 3. — Corporal M. C. Pember, Co. D, 33d Wisconsin Volunteers, aged 28 years, was wounded at the battle of Spanish Fort, Alabama, April 3d, 1835, by a conoidal musket ball, which fractured the right clavicle, and perforated the upper lobe of the right lung. He was received into the field hospital of the Sixteenth Corps, where resection of the outer third of the clavicle was performed by Surgeon Edwin Powell, 72d Illinois Volunteers. Several days afterward the wounded man was transferred to the Marine Hospital at New Orleans, where he died on April 12th, 1865. Case 4. — Private Charles Baker, Co. D, 31st United States Colored Troops, aged 20 years, was wounded at Petersburg, Virginia, July 30th, 1864, by a cf)noidal ball, which entered at the middle of the right scapula, penetrated the right lung, and emerged, fracturing the inner third of the clavicle. He was treated in the hospital of the Ninth Corps until August 17th, when he was transferred to Satterlee Hospital, Philadelphia. When admitted, the outer end of the denuded clavicle was protruding, and the patient was suffering from bed sores, which became worse. Appliances for the bed sores were made. On September 8th, the protruding portion of the clavicle was excised. Simple dressings were applied, and stimulants and tonics administered. Sept(‘mber 25th : System becoming exhausted from the siqjpuration. October 4th : A pyaemic chill occurred. Death resulted on October 6th, 1864, from pymmia. The case is reported by Surgeou I. I. Hayes, U. S. V. Sr.cT. II].] EXCISIONS OF THE CLAVICLE. 559 Case 5. — Corporal Freeman Scott, Co. L, 21st Pennsvlvania Cavalry, aged 18 years, was wounded at Cldckalioniiny liivcr, Virginia, June 2d, 18!j4, by a colloidal ball, wbicb struck the li‘ft clavicle about its middle, producing a comminuted fracture, jiassed downward and backward, and lodged apjiarently beneath the scapula. He was admitted to Stanton Hospital, ■Washington, on June 4th. The wound was suppurating jirol'usely but of good quality; the broken ends of the clavicle over- lapping each other; they were denuded of periosteum and bathed with pus ; they were surrounded by a cavity filled with pus, which extended down almost to the artery, and there was great danger that the sharp end of the underlying fragment would be driven into the artery by an unlucky movement of the elbow. The general health of the patient was favorable. On June IJth, 1864, ether was administered, the wound of entrance dilated by an incision on the front of the clavicle, and two inches of its middle third excised with a chain saw and the osteotome, great care being taken that the subclavian artery should receive no detriment. The portion resected was denuded of periosteum, and lying in a cavity filled with pus. Death occurred from jdeuritis on June 23d, 1864. The case is reported by the operator. Surgeon John A. Lidell, U. S. V. The three following cases had a more successful issue : Case G. — Sergeant J. H , Co. I, 9th New York State Militia, was admitted to the hospital at Frederick, Maryland, September 23d, 1862, with a gunshot wound of the shoulder, received at Antietam on the 17th, by the bursting of a shell. On examination, it was found that the outer half of the clavicle had been torn away ; this, with a fracture of a portion of the spine of the scapula and of the acromion process, allowed the shoulder to drop down. The soft parts abov'e the joint had the appearance of having been much torn and lacerated and were in a sloughy condition. Stimulating dressings were applied, and in about.two weeks the slough separated, leaving a granulating idcer six inches in length and four in breadth. Although the sloughing had been quite extensive, the joint remained uninjured. Doctor Gurdon Buck, of New York, while inspecting the hospital, had seen the case, and advised an operation, which he performed on October 12th. The patient was etherized, and the outer portion of the clavicle as far as the attachments of the sterno-cleido-mastoid muscle was removed by chain-saw. The integuments above and below were then dissected up and brought together by iron-wire sutures. The forearm was bent at a i-ight angle with the arm, which was raised to a level with the shoulder, and put in position by Smith’s anterior splint. The case progressed very favorably ; on December 12th, a tubular sequestrum, about two and one-balf inches in length, was removed; on the 16th, another small piece of bone came away. On January 16th, 1883, the patient’s general condition was good. An examination with a probe revealed some small fragments of bone, which had prevented the complete cicatrization of the wound. He was discharged from service on Jlarch 13th, 1883, at which time there -vyas paralysis of the arm. The acromial and outer cylindrical portions of the necrosed clavicle were forwarded, with a history of the case, by Assistant Surgeon R. F. 'VYeir, U. S. A., and are represented by the wood-cut (Fig. 256). Pension Examiner W. M. Chamberlain reports, March 20th, 1863: “There is no power in the arm, and the wound is not fairly closed. '*a! Disability mostly permanent.” M. M. Case 7. — Lieutenant Colonel H. N. Whitbeck, 65th Ohio Volunteers, aged 37 years, was wounded at Kenesaw, Georgia, June 27th, 1864; the missile fractured the left clavicle in its middle third, and lodged in the cavity of the thorax. He was taken to the hospital of the 2d division. Fourth Corps, where simple dressings were applied to the wound. On July 2d, he was trans- ferred to Officers’ Hospital, Nashville, Tennessee. The wound was inflamed and discharging thin sanious pus ; granulations exuberant; patient feverish and restless; pulse 110. On June 15th, Acting Assistant Surgeon J. A. Hall excised two and one- half inches of the middle third of the clavicle thiough an incision three inches long. He was furloughed on August 1st, and was afterward placed on court-martial duty at Nashville, until finally discharged from service on August 16th, 1865. I’ension Examiner A. D. Blein reported, December 2d, 1835: “ Ball entered left lung ; not yet extracted. Wound not healed. Another ball passed through arms, entering the side of the body, passing out on the other side superficially. Disability total but tempo- rary.” Lieutenant Colonel Whitbeck visited the Army Medical Museum, January 13tb, 1870, at which date he stated the wound had not permanently healed. It had re-opened four times during the previous year. He enjoyed com])aratively good health. He was a pensioner in March, 1872. Case 8. — Private J. H. N , Co. B, 10th Ohio Volunteers, aged 25 years, a robust German, was wounded at Perry- ville, Kentucky, October 8th, 1862, by a minie ball, which jiassed through the left shoulder and shattered the acromial half of the clavicle. He also received a gunshot wouml of the left hand. He was taken to the field hospital, where the ring finger was amputated at the metacarpo-phalangeal joint. On October 14th, he was transferred to No. 1 Hospital, New Albany. On the 17th, the acromial half of the bone was removed at the articulation, through a straight incision, by Acting Assistant Surgeon A. S. Greene, who contributed the specimen, represented of natural size in the adjacent wood-cut (Fig. 257), with notes of the case. Shreds and strips of periosteum were left in the whole course of the removed hone, and the wound was closed hy numerous stitches of iron wire. No adhesive strips were applied. He was discharged from service on January 6th, 1863, at which time perfect new bone had formed throughout the wound. The shoulder drooped forward a little, but the motion was good. This pensioner was paid to June, 1867, and Pension E.xaminer AV. Owen reports his disability total and pjermanent. The specimen was forwarded by Surgeon W. Varian, U. S. V. Fig. 2.57. — Shattorcil acromial Imlf of loft clavicle, excised for fjim- shot fracture. *S/?cc. 372, Sect. 1, A. M. M. 560 WOUNDS AND INJURIES OF THE CHEST. [CuAr. V, In some of the gunshot fractures of the clavicle described on pages 483 and 522, splinters of bone were removed. In the following interesting case, the fractured ends of the bone were removed : Case 9. — Sergeant J. M. Woodell, Co. I, 63d Massachusetts Volunteers, aged 45 years, was wounded at Port Hudson, Louisiana, May 27th, 1853; tlie missile entered near the sternal end of the right clavicle, passed backward and outward, com- nunuted the clavicle and neck of the scapula, the scroniion and coracoid processes of which it fractured, and escaped through the scapula, just below the spine. It also fractured the first and second ribs at their middle, wounded the subclavian artery and vein, and injured the brachial plexus. The jiatient was conveyed to New Orleans, and admitted, on the 29th, to the University hosj)ital. The loose fragments of bone were removed, the fractured ends of the clavicle rounded oft', and cold-water dressings apjdied. Death resulted on June 7th, 1863. While in hosj)ital, and for several hours after death, the right side of the chest and right arm were several degi'ees warmer than the corresponding parts of the left side. The necropsy revealed the injury done by the hall. The subclavian artery was not opened, though the inner coats were much lacerated, where the artery passed over the first rib, so much so that the vessel was torn in removing it. The subclavian vein was torn, and an imperfect coagulum filled up its cavity. The outer cord of the brachial jdexus was torn across. Specimen No. 1304, Sect. I, A. M. M., shows the clavicle, scapula, and first and second ribs of the right side. It was contributed, with a history of the case, by Assistant Surgeon P. S. Conner, U. S. A. Tlie subject of the following fatal case of partial excision had undergone also an amputation at the wrist: Case 10. — Corporal IF. II. Hushj, Co. I, 3d South Carolina Regiment, while in the act of firing, November 18th, 18C3, was wounded by a hall from au Enfield rifle, which struck the left hand, injuring it severely, and, after passing through many folds of blanket, struck the riyht clavicle about two inches from the sternal articulation, fracturing and comminuting the bone for the space of about two inches, and sjditting the sternal end to within a half inch of the articulation ; it then passed through the upper part of the humerus, entering at and breaking the inferior edges of the cartilaginous surface of the head of the bone, and coming out near the upper part of the attachment of the teres major and latissimus dorsi. On the next day the left hand was amputated about an inch above the wrist. In a report of the case the Confederate States Medical and Surgical Journal, Vol. I, page 159, Assistant Surgeon E. L. Johnson, P. A. C. S., says: “The case came under my charge on the 4th of December, at which time nothing was known of the position of the ball. The surgeon who first examined the case was necessarily ignorant of the fact that the humerus was injured, for it was not broken in two, but shot through, which caused, however, some .splintering. December 5th : Wrist (stump) doing \vell ; right arm very much swollen, probably on account of an abscess in the anterior part of the shoulder, which ])resses on the veins. December 16th : Ligatures came away from the stump. December 19th : Ordered whiskey, eggs, milk, and other 'nourishing diet, which have just been obtained for the first time. December 24th : The discharge of pus is now from one to two gills per day. It escaped by overflowing of the wound at the clavicle, the quantity being much augmented by pressure on the anterior part of the shoulder, over the abscess. December 25th ; Dr. Spinks, of Humi)hrey's brigade, and Dr. North, of Anderson’.s, were consulted to-day, and it was agreed : 1st. To ])ut the i)atient under the influence of chloi'oform, in order to make a thorough examination. 2d : To remove the ball, if its position could be ascertained. 3d. If the shoulder-joint has not been injured, or any other serious injury been done by the ball in its progress, to remove all necrosed portions of the clavicle. December 23th : Through the kindness of one of the Federal surgeons at Knoxville, I procured a good and complete set of resecting instruments. December 27th: The following operation was made to-day. Assistant Surgeons Spinks, Dygott, and Gotten, and Dr. Allen, being present : The patient having been aiifesthetized, was placed upon the table, and a large gum catheter was introduced into the wound and passed outward along the sinus to the anterior part of the shoulder, where there was a collection of [tus, and where the ball was supposed to be. Nothing more was gained by this step than a knowledge of the exact position of the abscess. The arm was then moved about to ascertain whether or not the humerus was fractured ; and as there was no crepitus, uo displacement, and no impairment of the movements of the joint, it was decided that the humerus and shoulder-joint were intact. An incision about two inches long was then made at the anterior edge of the deltoid muscle, and j^arallel with it, reaching from opposite the head of the humerus to below the neck. After cutting nearly an inch deej) through the swollen tissue, the knife entered the abscess. The finger was then introduced, and a large abscess was found with one sinus leading to the wound at the clavicle, and one leading around under the skin and fascia to another abscess, which lay in the posterior part of the shoulder. The first or anterior abscess contained pus and a few small spiculae of bone. The second or posterior contained dark, filfliy pus, and the ball, which was extracted. The clavicle was then resected. The existing orifice was enlarged by incisions — one extending neai’ly to the articulation of the left clavicle and sternum, the other extending over the distal fragment for about two inches. The sternal end was then disarticulated and removed by dissection. All spiculajwefe then carefully removed from the wound. These spicuhe were generally furnished on one surface with i)eriosteum, by which they grew to the tissues. Their other surfaces being free, and acting as foreign bodies, were surrounded by pus. There was one point, howev'er, at the bottom of the wound, about one inch and a half long, which was firm and immovable and covered with healthy gi'anulations. Tliis was supposed (at the time) to be a poi tion of the clavicle from the posterior surfiice that had never been displaced, and as there was no collection of jjus under or around it it was not removed. A chain saw was then passed under the distal fragment an inch from the broken end, the bone sawn in two, and the fragment removed by dissection. Though no veins or arteries of any size were cut, he lost over half a pint of blood, the tissues being very vascular. A few .sutures were taken ; wet lint was a))plied; the patient was put to bed, and mor))hine and whiskey were administered. December 28th : Rested well last night ; very pale and languid to-day ; without appetite and with some diarrhoea ; a counter opening was made into the abscess from which the ball hud been extracted; prescribed one grain of oj)ium, ordered eggs, whiskey, «fcc. December 29th : Has a little more color in his cheeks to-day than he had yesterday ; eat s(iuirrel stew with great relish ; bowels bett^u- ; Sect. III.] EXCISIOKS OF THE CLAVICLl':. 5G1 prescribed tr. catechu, gave whiskey, eggs, milk, »fcc. ; the opeiiiugs in the shoulder are discharging freely to-day, the discharge from the wound being much diminished. The swelling of the arm is so much reduced as to slacken the bandages, the first of which were apjdied on the 5th instant, and which had been re-applied every two or three days since. The arm reduced about one-third. December 30th and 31st: Doing well. January 1st, 1864: Doing well; appetite good; wound and incisions granulating; discharge from the wound much diminished, there not being enough to overflow the wound in twelve hours; the discharge from the anterior incision (in which a tent isTcept), which is now the outlet from the abscess in the shoulder, is less than the discharge was from the wound before the operation. January 7th: Healthy granulations over the end of the bone, and, indeed, everywhere about the wound; discharge, which is from the shoulder, very slight. January 8th: In the afternoon, some diarrhoea; presci'ibed tr. opii, tr. catechu in equal paifs, twenty drops after each operation on bowels. January 14th: Whiskey supplies have been out since the 7th ; diarrhoea has been constant ; prescribed tannin, catechu, opium, &c., with no effect; losing flesh and getting weaker. January 21st: Diarrhoea constant; patient very weak; procured whiskey to-day. January 26th : During past six days have had good supply of stimulants ; patient very weak ; diarrhma continuas ; will probably not live till to-morrow. January 27th : Died at one o’clock i». M. T\\q post-mortem examination revealed the course of the ball. On making an incision from* the wound, which had healed to a considerable extent, to the incision on the front part of the shoulder, and from there around to the posterior incision, I found the track of a large abscess. This also extended downward in front, and parallel with the pectoralis minor. At the bottom of this branch abscess there was a spicula of bone half an inch long. The ball had passed through the head of the humerus, but had not broken it in two. It did not pass, therefore, in front of the shoulder, through the sinus by which it was extracted. WTierever any periosteum was left, bone was forming rapidly. The hard, firm place in the bottom of the wound, supposed during the operation to be a spicula from the posterior part of the clavicle, proved to be entirely new bony formation. The .abscesses around the head of the humerus were large, and had burrowed back into the shoulder to some extent.” The eleventh and last of this series of operations on the clavicle was practiced for necrosis following a simple fracture of that bone ; Case 11. — Private John Q , Co. E, 9th New York Cavalry, sustained a comminuted fracture of the right clavicle, by his horse being shot during a charge into Winchester, Virginia, June 8th, 1862, and falling upon him. He was conveyed to Washington and admitted to Finley Hospital, where he was found to be suffering from gener.al emphysema, the result, probably, of a wound of the apex of the pleura from some of the fr.agments of the broken bone. He was treated for this difliculty for a considerable time and lin.ally entirely recovered. Several spiculse of bone were removed through an incision from under the skin in the situation of the sternal extremity of the clavicle. On October 21st, 1863, he was admitted to St. Joseph’s Hospital, Central Park, New York. The wound over the sternal aspect was still open and presented the pouting and indolent appearance indicative of dead bone at its bottom. A probe being passed into this opening disclosed bare bone, which was still firm in its attachments and which was decided to be a portion of the head of the clavicle. His condition was good and it was thought best to wait until the sequestrum should detach itself before any attempt at removal should be made. January 14th, 1864, an abscess formed over the outer third of the clavicle which was opened and showed the existence of dead bone at that point also. Simple applications were made to both wounds. February 10th: The sternal extremity of the clavicle commenced to protrude itself through the inner opening and was found to be connected with and evidently to form a solid piece with that portion of sequestrum felt through the outer opening. It w.as thought that the whole of that portion of the bone between these two points was dead. There was a considerable amount of thickening around it caused by the deposit of involucrum. The wound dis- charged slightly. June 1st: The bone was now freely movable in its bed and its sternal end pointed out of the wound for a distance of three-fourths of an inch. Aside from a pain in the right side of the chest and in the right shoulder, with .an incon- venience in the motion of the parts, the patient sufl'ered very little and enjoyed a good api)etite. On June 21st, 1864, Acting Assistant Surgeon J. K. Merritt removed the sequestrum by slightly enlai’ging the intern.al opening. The parts fi-om which this portion of bone was removed soon became firmly braced by a new bridge of osseous tissue, formed l)y the involucrum, and really constituted a new clavicle. The motions of the arm, though somewhat restrained, were nevertheless good, all the support to the shoulder necessary for the subsequent good use of the limb being left good. The case progressed well until July 16th, when the wounds covered themselves with an ashy slough and hospital g.angrene fairly declared itself. On the 10th, a thick .angiy-looking slough covered both wounds; the edges of the openings were tumid and inflamed. The surfaces of the ulcers were touched with bromine, but the sloughs were so thick that the remedy failed to have the desired effect. On the 14th, the sloughs were removed and bromine applied directly to the part. By the 10th, the gangi-ene had extended itself into the tr.ack which communicated between the two wounds. The p.atient complained of a gre.at deal of pain and soreness. Bromine was introduced into the track of the wound, but owing to the presence of the slough and the difliculty of removing it, the remedy could not be brought in direct conhact with the surfaces underneath. The parts were repeatedly touched with bromine and bathed with a wash made of the same. Under this treatment they assumed a healthy aspect .and the patient commenced to do well. By September 10th, the p.arts had entirely healed ; there was a marked enl.argement from deposit of new bone at the seat of exfoliation. The soldier was discharged from service October 1st, 1864 ; the arm was useful and nearly all the normal movements could be made with it. The sequestrum is repre.sented in the adjoining wood-cut (Fig. 258). It is partially tubular and is about three inches in length. The sternal articular surface is destroyed .as well as all the cancellous structure in the longitudinal diameter of the bone. . I It is evident, too, that the acromial end of the clavicle did not become necrosed, and the deficiencies of the compact tissue of the head portion of the bone may be accounted for by the removal of the several small „ . 1' 10.2.58. — 1 ubolar seqoe.sfrum from necrosis of nght clavi- fragments at the hospital at VVashmgton. The excavation on the anterior cle. Spec. 4332 , Sect. I, A. M. M. 71 662 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V, face of tlie hone was proliahlv caused by flie removal of two or three detached fragments at that time. If there were any small fragTiients toward the sternal end, as doubtless there were, they must have been firmly attached to the periosteum and become incorporated with the involucrum, and helped to form tlie firm bridge of bone which exists over the subclavian vessels. The specimen was contributed, with a history of the case, by Acting Assistant Surgeon G. F. Shrady. Excisions of Portions of the Scapula. — The comjfarative frequency of fracture of the shouhler-hlade in gunshot wounds of tlie chest has been referred to on page 484 of this Chapter, and examples are there cited of the removal of loose splinters of hone, as part of the ordinary dressing of such injuries. Sometimes, it is necessary to excise undetached portions of bone, to facilitate the extraction of jirojectiles, fragments of clothing, or equip- ments, or other foreign bodies. When great comminution has been produced, it may be advisable to excise considerable portions of the bone. When necrosis involves the larger jiart of the scapula, it should be extirpated. The last assertion is justified by the argument of ])r. Stephen Rogers, whose admirable paper’*' on the subject conclusively establishes the apparent paradox that it is safer, in cases of malignant disease, to excise the whole than a part of this Ijone. Excision of the entire scapula has thus far been practiced in military surgery only in connection with ablation of the arm; in other words, as an amputation above the shoulder. It was thus successfully performed by Gumming, in 1808, in the case of a man with gunshot comminution of the liumerus and scapula, and a similar operation, for the same cause, was successfully practiced by Gaetani Bey, in 1838, on a boy of 14 years. The removal of the entire scapula and preserving the arm is an advance of modern surgery whicli must undoubtedly be acknowledged as a legitimate resource in military practice in cases of extensive necrosis following gunshot fracture. So far, I believe, there is no recorded instance of its employment; although Dr. Neudorfer, of the Austrian army, in 1862, successfully removed the greater part of the scapula, in a case of necrosis caused by gunshot comminution. In our late war, the several partial excisions enumerated in the following series were practiced, and others that will be found detailed at page 492, et seq., of the Second Surgical Volume. Case 1. — Private F. E. B , Co. F, 5tli Connecticut Volunteers, aged 51 years, was wounded at Cbaneellorsville, Virginia, May 3d, 1863, by a conoidal ball, wbicli struck the infra-spinatus fossa of the left scapula about niidw.ay between its inferior angle and the .spine, passed forward, splintered the bone extensively, and finally lodged in tlie glenoid cavity without injuring the humerus. He was treated in the field liospital of the 1st division. Twelfth Corps, until the Cth, when he was sent to Lincoln Hospital, W'ashington. An operation, for the removal of the ball, discovered a large number of shattered fragments lying near the joint, which w'ere dissected out from their ligamentous attachment and withdr.awn. The lower portion of the scapula being now entirely separated from the ujiper, and, not knowing to what extent the inferior portion of the bone had been splintered, it was determined to remove it rather than risk the effects of the prolonged discharge from the remnant. Chloroform was administered, and the operation performed by Surgeon H. Bryant, U. S. V. The sjiine and supra-spinous fossa were jireserved. The smooth head of the humerus was visible through the wound. The patient did remarkably well. No bad symptoms supervened, and he gradually regained his strength. The incision made for the removal of the bone filled up without sinuses or discharge of exfoliations. On August 20th, he was furloughed for sixty days. Upon returning, the wound had entirely * ROOEHS, S., Case nf Excision of the Entire S:apula, to which is added a Ilistory of the Operations involving a Kcmoral of all or a Considerable Part of this Bone; with the view nf establishing the surgical Character and Prognosis of this Class of Operations. In Am. Jour, of tlie Med. Sci., N. S., Vul. LVI, p. 359, ]8(>8. [.See also Dr. S. Rooniis's p-aper in the A’cio York Med. Jour.. 18()9, Vol. VIII, p. 433.] [“Entirely a modern aeliievement in surgery," said .Sir W’illiam Fcrgu.sson (Lectures on the Progress nf Surgery, London, 18G7, Lecture 2, p. 47), and awarded the credit of first practicing if to .Syme. It was first performed by 15. von Langenheck, in 1855, for osteocophaloma. in a boy of 12 years ; next by .Syme, for a “sanguineous cyst of the bone," in a woman of 70 years ; third, by Dr. J. F. Ileyfelder, in 18.57, for caries in an adult, who died on the eighth day of pyiemia (Deutsche Klinik, 1857); by Mr. Jones, of Jersey, in 18.58, (Med. T. <£■ , Gazette des Uopitaux, Paris, Pevr. 4, 1871. Velpeau cites MarescliaFs case of trephioing the scapula, iu the Mem. dc VAcad. de Chir., T. II, Ilistoire de I’Acad, p. lx. , Pig. 265. — Right scapula, portion of clavicle, and head of humerus, showing results of gunshot fracture. Spec. 720, Sect. I, A. M. JM. inflicted the injury. The specimen (Fig. 264) is represented of a size Fig. 264. — Spine of the right scapula, excised for necrosis after ooinminution by a conoidal musket ball, a portion of which is attached. S2)ec.7\)4, Sect. I, A. M. M. of such a condition; Fig. 263. — Necrosed portions of the right acromion and spine of the scapula. Size of nature. Spec. 415, Sect. 1, A. M. M. Sect. III.] EXCISIONS OF THE SCAPULA. 565 In the Army of the Loire, at the engagements about Orleans, in October, Hovemher, and December, 1871, M. A. ChipaulL removed large portions of the scapula in three cases of gunshot comminution, as follows : Ca.se 1. — Gleizal. aged 23 years, 27th marching regiment, was wounded, December 2d, 1870, at I’oiirpry, near Artenay and admitted, December lOtli, to the ambulance at the Visitation. A musket ball had shattered the sub-spinal blade of the right scapula. Ou January 2Cth, 1871, M. Chipault removed about half of the bone below the spine, carefully ])reserving the periosteum. The patient was discharged, nearly well, April 2d, 1871. Case 2. — Weber, aged 35 years, 40th marching regiment, received a gunshot comminution of the right scapula at Neuvilliers, December 2d, 1870, the ball entering at the acromion and making its exit at the posterior angle of the spine. Admitted to the Visitation, December 18th, whei’e, on Februai’y 11th, 1871, the spine and acromion were excised. There was rapid reproduction of bone, tbe operation having been sub periosteal, as described, and the upper extremity regained its functions except ;U)duction of the arm. On May 11th, the patient was discharged from liospital. Case 3. — Klein, aged 22 years, 33d marching regiment, was wounded at Ormes, October 11th, 1870, by a ball, which comminuted the su])ra and infra-sj)inous portions. and spine of the right scapula. He entered the Orphan Asylum Hospital .Inly 1st. 1871. There was extensive necrosis, for which M. Chipault excised nearly the entire scajuda, the glenoid cavity, coracoid, and acromion being left. The patient recovered and preserved some use of the upper extremity. Dr. Chipault illustrates these cases by six chromo-lithographs, representing th,e appearance of the patients after partial recovery, and the pathological preparations of the comminuted scapulae. M. Chipault also publishes a case communicated to him, by Dr. Charpignon, which may be abridged as follows : Case 4. — Gerin, 7th battalion. Foreign Legion, at Orleans, October 11th, 1870, had his right scapula comminuted by a ball, which struck between the clavicle and first right rib, and passed out through the shoulder-blade. On October 23d, the wound wuis enlarged, and several necrosed fragments of the scapula were extracted. Some of them were so adherent that it was necessary to divide the muscular attachments. The patient recovered, and, in December, was sent to serve in Africa. He pr(!- served tbe use of his arm completely. Velpeair describes a patient on whom he practiced quite an extensive excision of the acromial portion of the scapula, for a comminution by grapeshot, in Paris, in July, 1830. j\I. LegouesD also mentions a case in which a ball, grooving the external border of the scapula, lodged under the glenoid cavity, so that he was “ compelled to resect largely to remove the projectile.” From the Crimean AVar, but one instance of partial excision for fracture of the scapula is noticed in Matthew’s statistical return {pp. cit., p. 372). The case is fully described in a paper on excisions, read at the twelfth ordinary meeting of the Crimean Medical Society [Med. Itvics and Gazette, September, 1856), March 20th, 1856, by Surgeon Thornton, of the 9th regiment, the operator in the case. Dr. Watson ■* states that “when attached to the surgical hospital above Balaclava, I had the opportunity of seeing several cases of fracture of the scapula from grapeshot. I recollect one case in particular, where the ball was lodged beneath the scapula, from which position it was extracted by incision about a month aftei’ the infliction of the injury. In this instance the whole of the bone was extensively comminuted, its processes alone remaining intact. In spite of this extent of injury, the fragments in great part retained their vitality, and, although the discharge was for a time both copious and exhausting, the part consolidated, and the patient recovered with the loss of scarcely any bone. I have also seen the head of the humerus, the coracoid * M. CinPAULT, A. — Fractures par Arrays a Feu Expectation^ Resection sous-p6riostee ^cidement. Amputation. Iloyal 8°, Paris, 1872, ^VELI’BAU, Med. Op6rat. (already cited), T. 11, p. 571. ^LegoUEST, TraiU dc Chirurgie d' Arm^^ 2cme §d., p. 325. The specimen is presented at the Museum of Val de-Grdcc. See op. cit. Ficf. 45. ‘^Edinburgh Medical dfrurnal^ Vol. XV, p. 124, 1809. This writer prints a history of an amputalimi of the scapula ami “adopts,” as lie terms it, I>r. Stephen* Kogeus’h table, dislocating it into subdivisions. As he “ rearranges ” it, tlie priority of excising tlie entire scapula ami iircserving the arm would appear to belong to an Kdinburgh surgeon, Syme (1850), instead of to Laxgendeck (1655). The legitimate fruit of Dr. llOGEUS’s industry is be preferred to Dr. Watson’s adoption. WOUNDS AND INJURIES OF THE CHEST. [Chap. V, 5()6 process, and glenoid surface so injured by a conical ball as to recpiire excision of lire bead of the humerus and the extraction of the primary fragments of the scapula.” Sir William Fergusson says,^ “I can scarcely imagine any case of compound fracture of the scapula where removal of the whole of that bone would be justihable as a primary proceeding.” Dr. P. H. Watson says, “ To this remark, I most cordially adhibit my concurring testimony.” Undoubtedly, a combination of circumstances that would render a primary excision or amputation of the scapula for gunshot comminution advisable can seldom arise ; yet, without a very vivid imagination, one may conceive of conditions, resulting from lacerations by large projectiles, which would render primary interference by extirpating the scapula and preserving the arm, or by amputation above the shoulder, not only justifiable but imperative. As a general rule, after removing detached fragments, the military surgeon will await what nature will accomplish in consolidating the fraotured bone, and will reserve excision, as an intermediary or secondary measure, in cases of extended necrosis." Excision or Removal of Portions of the Ribs.— This is a very old operation ; but its applications in military surgery are not very numerous or important. The smoothing off very sharp pointed ends of ribs fractured by balls, and extraction of loose fragments, constitute the only admissible primary interference. When necrosis supervenes, more extended operations are required. The cases of Grallagher and Butterfield, printed on pages 506 and 551, describe the ordinary partial excisions resorted to in the ribs. Some details are given in the following series of cases ; Cask 1. — Private J. H. Havvortb, Co. D, G9tlt New York Volunteers, was wounded at Antietam, Maryland, September 17tb, 1862, by a conoidal ball, wbicb entered on tbe twelfth rib, right side, two inches anterior to its angle, and emerged on the same rib, posteriorly, six inches from tbe first wound. He was admitted, on tbe 24tb, to tbe hospital at Frederick, where, on December 2d, Surgeon H. S. Hewit, U. S. V., excised tbe posterior portion of tbe tenth rib on the right side. He recovered, and was discharged from service on January 1st, 1863, His name does not appear on tbe pension rolls. Case 2. — Sergeant Edward R. Barker, Co. G, 148tb New J.’ork Volunteers, aged 33 years, was wounded in tbe left breast by a conoidal ball, at Fair Oaks, Virginia, October 27tb, 1864. He was admitted, on the 29th, to Hampton Hospital, Fort Mon- roe, where, on January 11th, 1865, a portion of rib was excised. He was furloughed on March 16th, 1865; reported to hospital at Rochester, New York. On July 11th, 1865, he was transferred to Ira Harris Hospital, Albany, New York, whence he was discharged from service on July 29th, 1865. Examining Surgeon Jolin B. Chapin, of Canandaigua, New York, October 16th, 1866, reports : “Ball entered left breast betw’een the nipple and median line, striking the ribs, and emerging below, say, opposite the stomach. The course of the ball after striking the ribs was downward. Four or five ribs were fractured. The disability consists of an extensive cicatrix, involving the intercostal muscles and the origin of the pectoralis major muscle, preventing the use of the arm in a backward direction and interfering with respiration. The applicant states that he is also suffering from gun- shot wound in the calf of the leg, received June 3d, 1864, at Cold Harbor, Virginia. Leg lame; foot swells so that he can only wear a boot part of the time.” Case 3. — Private Peter C. Farnsworth, Co. F, 31st Maine Volunteers, aged 17 years, received a shell w’ound of the right side of the chest at Petersburg, Virginia, June 17th, 1864 ; the eighth rib was fractured at its centre, and the seventh and ninth ribs denuded on the same line. He was at once conveyed to the 2d division hospital of the Ninth Corps, where simple dressings were applied. On June 20th, he w'as transferred to Mount Pleasant Hospital, Washington. When admitted, the patient’s general health was good. There was slight inflammatory action in the integuments immediately about the wound. The fractured ends of the rib did not interfere with the action of the pleura. June 24th; Inflammation subdued, but no efforts at granulations ; stimulant injections and resin cerate dressings. On June 30th, physic.d signs of pneumonia made their appearance, localized about the seat of injury. July 4th, pneumonia resolved. Wounds and adjacent tissues in a sloughing condition. Secondary haemorrhage occurred from the intercostal artery, which couUl not be secured on account of the mass of slough. The wound was thoroughly injected with tincture of njuriate of iron and plugged with lint saturated with the same. The slough still advancing, the patient was etherized on July 8th, and the wound was thoroughly cauterized with nitric acid; a yeast and charcoal poultice was then applied. The remainder of the slough came away on July 12th; hmmorrhage recurred, and, the artery eluding search, * Feiigusson, a System of Practical Surgery, 5tU ed., 1870, p. 302. ^Consult further; Gross, S. D., Western Journal of Med. and Surg., od series, Vol. XI, p. 419. 1853; Blackman, G. C., Am. Jour, of the Med. Sci., N. S. Vol. XXXVI, p. 578; LOGAN, Richmond and Louisville Medical Journal, August, 1872, p. 131 ; the same. Southern Journal of Med. Sci., October, 1867. Dr. F. H. Hamilton (Prin. and Pract. of Surgery, p. 395) refers to an excision of the scapula for necrosis after gunshot injury, reported by liim in tlie N. Y. Med. Journal. ,Tanuarj% 1869. That number is missing in tlie otherwise complete file in tliis (Itlice. Sect. III.] EXCISIONS OF PORTIONS OF THE RIBS. 567 tlie treatment of tlie 4tli was succe.«sfiilly resorted to. The outer ends of tlie fractured rib were found to liavi; caused irritation by their friction motion on the pleura; and, on the Ihtli. Acting Assistant Sui-geon F. S. Barbarin administered an ana 3 Sthctic and removed the diseased portions of the fractured ends of the eiglith rib ; all the diseased portions of the seventh and ninth ribs looking toward the eighth rib were removed by the nippers and smoothed with a lenticidar. But little blood was lost, and the )iatient reacted promptly. After the excision, the condition of the patient impi'oved in regard to breathing and a])])etite. He did well until July 2Gth, when by some sudden movement, while walking in the hall of the hosjiital with the assistance of crutches, he fiactured the ninth rib. Jul3-2()th; Treatment continued; quite comfortable, but irritable. August 8th: In a very feeble condition. Suttering acute pain over the whole abdomen, with frequent discharges from his bowels. Pulse 120. He gradually became weaker, and died August 13th, 18(i4. At tin; necropsy the upper and middh; portions of the right lung were found to he partly adherent to the costal j)leura by thin fibrous bands. Assistant Surgeon C. A. McCall, U. S. A., reported the case. Case 4. — Corporal Ellsby McCoy, Co. D, 20th Maine Volunteers, aged 19 years, was wounded at Poplar Grove Cluuvh, Virginia, September 30th, 1864, by a conoidal ball, which entennl the chest on the left side, fractured the fourth rib, and, glancing, lodged in the axilla on the same side. He was taken to the field hospital of the Fifth Corps, and, on October 7th, was trans- ferred to Lincoln Hospital, Washington. On October 20th, Assistant Surgeon J. C. McKee, U. S. A., administered chloroform and extracted the ball through an incision made along the border of the latissimus dorsi muscle; the end of the fractured rib was also resected. The patient was discharged from service March 23d, 1865. He is not a jiensioner. Case 5. — Private Daniel Fisher, Co. C, 27th Pennsylvania Volunteers, aged 22 years, was wounded at Gettysburg, July 1st, 1863, by a conoidal ball, which entered the lumbar region three inches to the left of the spine, ])assed superhcially upward and outward for about six inches, and lodged in the walls of the chest, lie was at once conveyed to the field hospital, where the ball was removed, with a piece of the rib, on July 4th. He subsequently fell into the hands of the enemy, was paroled in a few days, and, on the 11th, entered Turners Lane Hospital, I’hiladelphia. Water dressings were applied to the wound. He improved rapidly, and was returned to duty August 12th, 1863. The missile, oblicpiely liattened on one side of the body as if from contact with a stone, was contributed to the Army Medical Museum, pjg ogg _]\iysi;et h,,ii with a history of the case, by Assistant Surgeon C. II. Alden, U. S. A., and is represented by the ttattened by impact wiib adjoining wood-cut (T IG. 266). A. M. M. Ca.se 6. — Private Andrew J. T , Co. F, 7lh Indiana Volunteers, aged 18 years, received a gumshot wound of the right arm and right side, fracturing the ninth rib, at Petersburg, Virginia, July 28th, 1864. He was taken to the field hospital of the Fifth Corps, where splints were applied to the arm. On August 1st, the arm was amputated at the junction of the middle and the iqiper thirds by Acting Assistant Surgeon C. II. Van Tagen. He was transfeiTcd to Lovell Hospital, Portsmouth Grove, Rhode Island, August 7th. When admitted he was suffering considerable pain ; appetite poor. On August 12th, Acting Assistant Surgeon E. Seyifarth administered an anaesthetic and removed a portion of the ninth rib through an incision three indies long. Simjile dressings were applied. The patient did well until September 10th, when he began to fail, and, in spite of stimulants, died from exhaustion, with empyema, September 24th, 1864, The sjiecimen of the amjuitated arm is No. 4725, Sect. 1, A. M. M., and was contributed by the ojierator. Peculiar Shot Fractures of ilie Fibs. — Here there is tin ()|)|)ortunitv to advert to some other varieties of fractures of the ribs than those described on i»ao;es -188, 490,'-' and 521. The history of the case that furnished the curious perforation of the rib represented in the cut (Fig. 267) is printed on page 446 (Bugler B ), with wounds of the spine, the ball having also perforated the body of the vertebra. The missile has executed the first step in one of the proposed methods for ligation of the intercostal artery. Tlie following case exemplifies the rare occurrence of a “willow- fracture” produced by a musket ball; Case. — Private William T , Co. C, 33d North Carolina Regiment, aged 21 years, was wounded at Fredericksbuig, Virginia, May 3d, 1863, by a conoidal ball, which entered the right side at the eighth intercostal space. He lay on the held during the night in a rain storm and on the next day was conveyed to the field hospital, where he was treated until the 8th, when he was transferred to Lincoln Hospital, Washington. When admitted, his breathing was very laborious ; imlse rai)id, (juick, and non-compressible ; expression of the fiice anxious; sputa frothy and firmly adherent to the eu]) ; breathing carried on principally by the left lung. He said the saliva had been tinged with blood. Sedatives and expectorants were administered. May 19th: Patient suffers from cough, causing intense pain in side. He continued to fail, and died klay 21st, 1863. At the necroj)sy the right lung was found to be compressed, collap.stul, and pushed forward ; parenchyma i)ale red ; small bronchial tube prominent. The posterior surface was covered with a thick layer of recent yellowish lynq)h ; the anterior suifaco was of a pale greyish blue color and free from lymph. As viewed in situ the lung extended from the first to the sixth rib, jirojecting * See ante. Figs. 224, 228, 229, 231, 2:)3, 23.">, 23ti, 240. Fig. 267. — External and internal views of tlie anterior thinl of the eleventh right rib, perforated by a carbine ball. Spec.. 3291, Sect. 1, A.M. M. WOUNDS AND INJURIES OF THE CHEST. [Chap. \ 068 jiHlcriorly ncaily to tlip nn'diaii line. Tlie portion not visible was firmly bound to tlie ribs and anterioi- poi'tion of tbe diajiliraom by adhesions. The lung was sejiarated from the costal pleura by a large quantity of purulent matter measuring twenty-four ounces. The diaphragmatic and costal surfaces were covei-ed with a thick layer of lymph similar to that observed in the lung. The ball had entered the body on the right side, in the eighth inter- costal space, passed slightly downward and inward, fracturing the ninth rih a little anteriorly to its angle, passed through the diaphragm and upper posterior part of the right lobe of the liver, reentered the pleural cavity, having made a wide ragged track, and was .found l.ving on the diaphragm. The tr.ack of the ball was lined with lymph. The missile would ajipear to have struck the rib sidewise, and being much flattened (FlG. 269), after partially fracturing the rib to liave been deflected into the ninth intercostal space. The peculiar fracture of the rib is shown in the wood-cut (Fig. 268). The bone and missile are mounted together in the Museum specimen, which rvas contributed, with notes of the case, by Assistant Surgeon Harrison Allen, U. S. A. Fig. 268. — Extenial and internal views of a section of the rigid ninth rib, with a gunsliot willow’-fracture. Spec. 1141, Sect. I, A. JI. M. Fig. 269. — Sliisket ball flattened bv Uderal impact on a rib. Spec. till. Sect. I, A. M. M. Tliougli Specimen 3823, of willow fracture of the left fourth rib, hy a glancing shot, referred to on page 490, was from a slender man, who gave his age as twenty-eight years, yet we should anticipate that such lesions would occur commonly in very young subjects. A more com- mon form of gunshot fracture is rep- resented in the adjacent wood-cut (Fig. 270) from a specimen taken from a man of 46 years, wounded by a small fragment from a shell, at the battle of Mission Ridge. In the following remarkalde case, the patient succumbed from dysentery, and it was possible to observe the morbid alterations at the seat of fracture more than eight months after the injury was inflicted : Case. — Private Thomas P. C. C , Co. A, 9th Mississippi Regiment, aged 19 years, was wounded near Petersburg, Virginia, Nrivember 5th, 1864, bj’ a conoidal ball, wdiich entered the posterior portion of the left thorax, passed between the tenth and eleventh ribs, fracturing the latter, as well as the transverse process of the eleventh dorsal vertebra. He was treated in a Confederate hospital at Eidimond, and, on May 6th, 1865, was admitted into the hosjiital at Point Lookout, Maryland. On July 24th, he was transferred to Armory Square Hosjfltal, Washington, and, on August 17th, to Douglas Hospital. The patient stated that on the reception of the in.jui'y he had a free ‘hsemorrhage from the wound, spat blood, and had great difficulty of breathing, but that he was doing well until about the middle of June, when he was attacked with diarrhoea. On his admission to Douglas Hospital he was terribly emaciated — almost a living skeleton. On the 18th, the ball, which had lodged behind the tenth rib about one and a half inches from the wound of entrance, was removed by Assistant Surgeon William F. Norris, U. S. A. In spite of the free administration of beef tea and stimulants, with astringents and injections qf nitrate of silver for his dysentery, the patient sank rapidly, and died August 20th, 1865. An autopsy was made thirteen hours after death. There were strong pleuritic adhesions between both lungs and the walls of the thorax. The lungs were healthy except the lower lobe of the left lung, which was collapsed and firmly adherent to the w'alls of tin? chest near the seat of injury, in such a manner as to form a cavity of considerable dimensions between the wall of the chest and the lung substance. The liver and kidneys were fatty, the spleen healthy, the intestines shrunken and pallid, but everywhere healthy exce])! the descending colon and rectum, where the solitary glands were much enlarged and had ulcerated. They presented the appear- ance of small cysts, the size of q pea, with minute circular openings at the summit, and contained a transparent gelatinous mass. The pathological specimen is represented in the accompanying wood-cut (Fig. 271). The wound of entnuice in the fractured rib is well rounded, and the two are firmly agglutinated by osseous deposit. The preparation was contributed, with a history of the case, by the ojierator. Assistant Surgeon W. F. Norris, U. S. A. Fig. 271. — Posterior halves of tenth and eleventh left ribs, showing a consolid.ated fraoture by a conoidal ball, which is attached. Spec. 1561, Sect. I, A. M. M. Fig. 270.— Anterior two-tliirds of the foiirtli and fiftli ribs comminuted by a shell fragment. Spec. 2185, Sect. I, A. JI. HI. Sect. HI.] EXCISION OR REMOVAL OF PORTIONS OE THE RIBS. 509 C.VSE. — Sergeant James K , Co. A, 35tli Indiana Volunteers, was struck, Novenilx'r 2otli, 1863, by a fragment of sliell in the left chest, the missile penetrating the thorax. He was taken to one of tlie field hospitals of the Fourth Corps, where some fragments of bone wen? extracted and the ragged wound dressed simply, and the ribs confined by a broad chest bandage. There was much dyspnoea and anxiety, but little haemorrhage. The missile had lodged in the thorax. On December 1st, the patient was sent by rail to Nashville, and entered Hospital No. 1 on December 3d. His pidse was feeble, surface pale, tongue coated and dry. There was an offensive sero-purulent discharge from the wound, and a dry, hacking cough. He had pneumonia. He was treated by small doses of morphia, with iron and quinine, and milk j)unch. On the 11th, he had chills, and, on the succeeding days, rigors, with excessive reaction. He died from exhaustion on December 16th, 1863. There was a copious thin ])urulent •exudation within the left pleural cavity. The missile lay in the costo-diaphragmatic angle. Acting Assistant Surgeon W. H. Matlock forwarded the specimen, and the memorandum of the history was transmitted by Surgeon Caleb W. Horner, U. S. V. Not uncommonly a ball striking a rib at short range would drive before it such con- siderable fragments of the bone as would constitute two or more inches of its shaft. Such injuries were rarely attended Ijy bleeding from the torn arteries, but often by free haemorrhage from the lacerated pulmonary tissue. The adjacent wood-cut (Fig. 272) represents a specimen from such a case, in which the sharji, FKaSTO-Seotion of ninth rib. from which more than J^^Sgecl extreillitieS of the I’ib luul llOt bceil rOUlldecl two inches of the bodyof th3 bone were driven into the left /w-ff 1 .-ry lung by a conoidal musket ball. to the James River. From Harrison’s Landing, he was sent, in a hospital tran.sport, to Philadelphia, and was admitted to Satterlee Hospital, on July 31st, 1862. He lingered until August 25th, 1862. An autopsy was made by Professor Joseph Leidy, who contributed the specimen represented by the adjacent wood-cut (Fig. 273) and the following notes of the pathological appearances: “The light lung appeared to be sound in the upper lobe, but was collapsed and condensed in the lower ones. There were also extensive pleuritic adhesions ; and the pulmonary pleura of the lower part of the lung was much thickened. The pleural cavity was distended with an accumulation of pus and serum. The heart and left lung were normal. The liver was much enlarged and presented some fatty degenwation. The stomach, intestines, and spleen were .sound. The kidneys were large and presented some appearance of fatty degeneration of the cortical substance, which, however, was not confirmed by microscopic examination.” Beside the cases that have been cited of excision of portions of ribs, or removal of splinters, or extraction of necrosed fragments, five cases are found on the reports, noted too briefly to admit of precise determination of their nature. They may be included in the following : Memorandum. — 1. Sergeant S. L. Bowden, Co. B, South Carolina Palmetto Sharpshooters. October 7th, 1864. Excision of rib. Confederate hospital, Jackson, Mississippi. {Confederate Register, 49.) 2. Private Anthony Briggs, Texas Cavalry. Fragment of shell fractured two ribs, right side, below axilla. April 2l8t, 1863. Sloughing, exposure of pleural sac. Excision of one and a half inches of rib and a small segment of next rib, exposing the pleura pulmonalis for an irregular space of about one and a half inches square. Recovery. (Field note-book.) 3. Private B D , 40ih Illinois 'IMlunteers. Gunshot fracture of seventh rib. Chlorofonn administered and rib resected. Patient recovered. (Field register.) 72 570 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V, 4. I’riv.ito J. Snmicr, Co. I, Stli Ponnsylvania Cavalry. Gunshot woniid fracturing tenth and eleventh rihs, and penetrating liver. Diinviddie, JIarch 31st, 1865. Excision of portion of injured rib. Discharged September 2d. 1865. (Casualty list.) 5. Ihivate Michael Donnegan, Co. D, 17th New York Volunteers, aged 25 years. Savage’s Station, June 29th, 1862. Excision of portion of tenth rih. Nearly well September 9th, 1862. Dr. J. A. Reagan, of North Carolina, has published [Am. Jour, of the Med. Sciences, N. S. Vol. LIV, p. 564, October, 1867) an account of a successful excision of necrosed portions of the right fifth and sixth ribs in a soldier shot through the chest in August, 1863. The ball had entered to the right of the spine, split upon the fifth rib ; one piece emerging from the fifth intercostal space, while the other fragment lodged under the sixth rib. In July, 1865, Dr. Reagan, excised the necrosed portions of bone, extracted the ball, and evacuated a pleural abscess containing three pints of pus. The patient recovered rapidly, and, twenty-five months after the operation, was in robust health., The indications for excisions of the rib have been formulated by M. Demarquay as follows: First, when a foreign body is impacted in a rib; secondly, in some forms of frac- ture of the rib; thirdly, in cases of caries and necrosis; fourthly, in cases of cancer or tumors.^ The first indication would present itself when arrow-heads are impacted in the ribs ; ^ or the points of knives or swords are broken off in the shafts of ribs ; or when a pistol or musket ball is imbedded and cannot be extracted by forceps or screw. Thus, Malle, ^ in 1843, removed a broken knife-blade, impacted in the right fifth rib, including the foreign body, with a portion of the rib, in the crown of a trephine. In compound comminuted fractures, the circumstances of each case must determine the necessity and extent of surgical interference. It will be always proper to remove detached fragments of bone, even if driven into the lung tissue, and it may be necessary to saw off the splintered ends of the ribs. Yet when points of the inner lamina, still covered by periosteum, are bent inward, it may be safer to replace them by traction with a lenticular, hoping for consolidation, and preferring always that mode of dressing involving the least hazard of injuring the pleura; which will sometimes incur greater risk from the presence of the fractured ends, and in other cases from the operation for their removal.^ In cases of caries and necrosis, there is less difficulty in deciding when an operation is opportune and far greater facility in its performance; for the pleura in these cases is usually thickened and separated from the rib.^ The operations for tumors may present formidable difficulties; but need not be considered here.® ‘ SI. Demauquay { Gaz. Mid. de Paris^ T. XXIV, p. 30, ISfiO). I cite M. Demarquay as the latest author who has treated the subject systemat- ically. Dr. F. II. Hamilton (Princijdes and Practice of Surgery y 1872, p. 266) proposes another indication : “To exsect a portion of the rib in order to reach and secure the bleeding vessel” in some cases of hemorrhage from the intercostal artery, which is, I think, inadmissible. ^See Rejiort of Surgical Cases, c^c., Circular No. 3, 8. G. O., 1871, p. 160, for illustrations of this form of injury, and specimens 4735, 4736, and 4823 of the Army Medical Museum. 3 Malle (Traite d' Anatomic Chirurgicale et de Midccine OptratoirCy Paris, 1855, p. 660). M. Malle bbseiwes justly that Heine’s osteotome is a preferable instrument for such operations, but tins is a yory expensive instrument, rarely made except for the armamentaria of public institutions. Medical olficers should know that there is one, which they are at liberty to use, in the collection of instruments at this Office. '^Duverney {Traite dcs Maladies des Os), BOTTCIIER {Answahl d. Chir. VerhandeSy Berlin, 179.5), Goulard {(Euvres de ChirurgiCy Pizenas, 1766), Callisen (Systema. Chirurg. Hod. UajnitSy 1788) writes on this class of cases. KOUX reports a case in the Examinateur Medicaly Vol. I, p. 122. A full collection of cases is made by JjEGER, Ilandwdrterhuch der gesammten Chirurgie, Leipsig, 1839, Art. Resectio ossiuMj B. V., S. 424. ®Dr. WII.LIAM A. McDowell, of Fincastle, Virginia, was one of the first in this countrj^ to excise considerable portions of necrosed ribs. He describes in his Dissertation on the Pathology of the Bones {Am. Med. Recordery Vol. XIII, p. 119), the extraordinaiy operation he successfully performed June 25th, 1827, fur the removal of the greater part of the right sixth and seventh ribs. At that time the operation by PiCllERAND (the account is translated in the Medical Repository y New York, 1818, Vol, PV, p. 401), and that of ClTTADlNl (Annali univ. di Medicinay Milano, Marzo, 1826; but published in the Journal comple.mentaires of the great dictionary in sixty volumes, in 1820) w*ere about the only instances of this operation mentioned in the current siu'gical literature. Cittadini removed only the sternal extremity of the first rib, necrosed in consequence of the impaction of a stiletto point. He divided the cartilage with a probe-pointed knife, and the rib by cutting forceps. 6 Consult Professor S. D. Gross’s System of Surgery y 5th ed., Vol. II, p. 1080. M. DEMARQUAY, Article CoteSy in the Nouveau Dictiemnaire de Midicine ct de Chirurgie PratiqueSy P.aris, 1869, T. IX, p. 589, and the amplification of this article in a dissertation entitled Resection des cotes in the Gazette Medicate de Paris, 36me S6rie, T. XXIV, pp. 29, 56; Percy’s Article Resections, in the Diet, des Sci. Med., T. XLVII, p. 5.50; IliVERIUS, Ohservationes Medicarum Cehturise Quatuor, Ijugduui, 1763, p. 129; Communicated obseiwation by A. D. OziA AimaR, a most celebrated surgeon of Gratianopolis (Grenoble), Obs. Ill, relating to Dominus de Bessin, a contusion with extensive caries of the ribs, that had been treated by the actual cautery, until an openiTig into the thorax w'us produced that would admit the hand. Aimar removed four fingers’ breadths from the carious ribs, and Sect. III.] EXCISIONS OK THE STEKNUM. 571 Excisions of Portions of the Sternum.— Trephining of the inanuln-ium and gladiolus, which should he legitimately classed with excisions, has been recommended in cases of necrosis, and compound fracture of the bone, and to facilitate ligation of the internal mammary, and the extraction of foreign bodies from the anterior mediastinum. De la hlartinibre laid down rules for trepanning the sternum [Mem. de I Acad, de Chir., 1819, T. IV, p. 488); but Percy tells us [Chirurg. d' Armee, p. 123) that Purman was the first wlio performed the operation, and remarks naively that when a ball is lodged in the duplicature of the mediastinum, “ce seroit effectivement I’unique ressource dans cette conjoncture. Mais il faudroit auparavant etre bien sur qu’elle y fut, et on sait combien a cet figard les signes sont decevans.” A number of examples have been given of gunshot fractures of the sternum, laying open the mediastinal cavity so that the pulsations of the aorta and the heart were exposed. Conspicuous among these is the fortunate case of Private Betts (Plate X, opp. ji. 486). Dr. Judson’s case of ligation of the internal mammary (p. 548) after gunshot fracture of the manubrium and second rib, illustrated by the interesting specimen, Xo. 2925, of the Surgical Series of the Museum ; and the case observed by Dr. McGill (Powers, p. 535), in which the movements of the heart could be seen and felt through a perforation of the gladiolus, will also be remembered by the reader, and will recall the case described by Galen,'* *" and that of the son of the Viscount of hlontgomery, which afforded the immortal Harvey the occasion to demonstrate to His Serene Majesty Charles H the movements and the insensibility of the heart. f obtained a sound cicatrix. Demarquay says that Cercuus^ in the sixteenth century, was regarded as the author of the operation of resection of carious ribs. I do not find this name among the authors of the sixteentli century. Androuet Cerccati (1576) wrote on architecture, and J. A. Ccrceau, the only (>ther c-f the name known to bibliophiles, was a French Jesuit, who, in the next century, wrote verses "of mediocre quality,” according to Voltaire. I3ut M. A. Severinus advocated the excision of carious ribs, in the sixth book of his Synopseos Oiirurgisc, Amsterdam, 1664, p. 135, and cites Galen, Colsus. and Paul of iEgina, without misleading Champion, who, in 1815. published a thesis entitled liiscctions de.s os cariis dans \mr continuiete. (from which lil. Demarquay complains that writers have quoted without acknowledgment), and duly cites Galen {Methodus medendi, 1, v. ch. 8), Celsus {de Re Med. 1. viii, c. 2) and Soranus, of Ephesus, in the twelfth chapter of the collection made in the eleventh centuiy by Kicetas, of Constantinople. Ikiul of Higina (See Syd. ed. translation’, Vol. II, p. 453), after iireser^'ing the dregs of the Arabs in the honey of his Saronic Greek, has fared as badly as Champion at the hands of the plagiarists. Other observations of excisions of portions of necrosed ribs may be found in A. SCIIENKIUS, De Vuhi. thorac., Ohs. niedicinalium, Frankfurti, lt)G5, L. II, p. 297; LeVacheu, in the Mercure de France, April, 1858. IlICllEUAND’S famous case is printed in the Bulletin de la Faculte, T. VI. ROUX wrote on the subject in 1802, in his treatise De la Resect, on dn Rctrancli. des os malades. Moreau describes examples in his two essays, 1803 and 1815. See also CriTADixi, De la resect, des cotes (in Arch. G6n. de M4d., 1828, T. XVIII, p. 71) ; Clot Bey, for two cases {Jour. Hcb. 1825) ; Blandin, Kecrosc d'un cote (Gaz. des Hop., 1840, p. 373) ; FiORi, Resection de la totaliU d'une cote (Gaz. des Hop, 1842, p. 518, £r(un Annali univ. di Milano) ; IIeyeeldeu {op. cit., Bceckel's cd. p. 236) ; Largiii {Operazioni sotto-perinstee e sotto-capsulari, Torino, 1855. Professor Gross refers to a remarkable excision of the necrosed shafts of the sixth and seventh ribs, which he performed at the Jefferson College clinic, in 1857 ; and cites the extraordinary* exploits by Suif {Bernardus Suevns? in Haller) and Dr. ^lilton Antony, of Georgia (it is illustrated by a plate in the Phil. Jour, of Med. and Phys. Sci., Vol. VI, p. 108), and the formidable operations by John C. Warren, George INIcClellan, and William Gibson. Warren's two cases are printed in the Boston Med. and Sarg. Jour.. Vol. XVI, p. 201, 18:i7: George 5IcClellan’s case was published in the Western Jour, of Med. and Phys. Sci., Vol. IV, p. 479, 1831, and Dr. J. II. B. McClellan related its later history in the Med. Examiner, N. S, Vol. VI, p. 75, 1850. * Galen gives the Uistoria pueri p)ersanati cui os pectoris excisum erat, in his work de Anatomicis Administrationihus. It may be found in the Latin version commented by Vesalius, Liber VI, Cap. 13, in the Opera omnia, Tomus I, of tlie Basil edition of 15G2, as follows : " Quoniain vero semel curati pueri mentionem feci, nihil mali fuerit omnia, quo ipsi euencnit, perceusere. Xam propter historic utilitatem, etiam si ad prmsens opus nihil attineat, no abs re fuerit ea commemorfe. Ictus puer ille in pectoris osse in palaestra neglectus primum est, deinde parum probe curatus post menses quatuor pus in parte percussa apparuit hoc auferre cogitans medicus puerum incidit, an, ut putabat, subito ad cicatricem vulnus prerduxit postea rursus infiammatio oborta est, mox quoque absccssus iterum sectus puer est, nec amplius cicatrix obduci potuit. Quapropter herus ipsius pluribus mcdicis convocatis, inter quos ego quoque eram, deliberare .super curatione pueri iussit. Cum autem sideratio quam Greci c^a.Ke\T) appellant, pectoris ossis affectus videretur omnibus, appareret ante lied to it, those of the other to the artery at the wrist, as well as from their discordance with the respiratory movements — I saw was no portion of the lung that I was handling, but the apex of the heart ! covered over with a layer of fungous flesh by'- way of external defence, as commonly happens in old foul ulcers. The servant of this y'oung man was in the habit daily of cleansing the cavity from its accumulated sordes by means of injection of tepid w’ater ; after which the plate was applied, and, with this in its place, the young man felt adequate to any exercise or expedition, and in short he led a pleasant life in jicrfect safety’. Instead of a verbal answer, therefore, I carried the y’oung man himself to the king, that his majesty’ might with his own cy’cs behold this wonderful case: that, in a man alive and well, he might, without detriment to the individual, obser\’e the movement of the heart, and with his proper hand even touch the ventricles as they contracted. And his most excellent majesty’, as well as my-self, acknowdedged that the heart was without the sense o^ touch ; for the y’outh never knew when we touched his heart, except by the sight or the sensation he had through the external integument. We also particularly observed the movements of the heart, viz: that in the diastole it was retracted and withdrawn, whilst in the systole it emerged and protruded, and the sy’stole of the heart took place at the moment the diastolp or pulse in the wrist was perceived ; to conclude, the heart struck the walls of the chest, and became prominent at the time it bounded upward and underwent contraction on itself.” * See pages 486, 487, 488. 504, 523, 526, 535, 548. tSI. HirrOLi'Tic Larkey, in his lectures on surgery at Val-de-Grace, ascribes the frequent occurrence of necrosis of the sternum to the pressure of the soldier's cross-belts. Such an efl'ect has not been obsen’cd frequently in the United States service. M. Linoli has resected the xiphoid appendage {Annali univ. di medicina di Milano, 1851) fur obstinate vomiting. It has been affirmed by Percy’ that the xiphoid cartilage will sometimes recede before a ball and then spring back barring the opening, as observed by Guillemeau {(Euvres de Chirurgie, Rouen, 1649) in the case of M. do Mal6corne. If the sternum is very soft, it will not bear readily the pressure of the trephine or osteotome, and it will be necessary to resort to the chisel or gouge, as Boyer did, or the chain saw, as employ’ed by Dr. J. F. IlEYFELDER. MOREAU, Blandin, J.EGER, and KUCIILER removed diseased costal cartilages in their operations for partial excisions of the sternum. See JiEGER, Handivortcrhuch der gesammten Chirurgie, B. V, 8. 425, Leipsig, 1839 ; SKlELDEUUr, 0)1 the Operation of Trepanning the Sternum, translated from the Transactions of the Roy’al Society of Copenhagen, 1813, in Am. Med. Repository. N. S.. 1820, Vol. V, p. 273 ; Fergusson, Syst. of Pract. Surgery, 5th ed., 1870, p. 620 ; HOPTOX, Operation of the Trephine for the Remeycal of a Portion of Carious Sternum, Am. Jour. Med. Sci., Vol. V, p. 45, 1829 ; and among older authors, COLOSSIUS, De perforatione ossis pectoralis, Tubingen, 1775; Bu' 1 T('IIER, Abhandlungcn v. d. Krankhcit d. Knochen, T. I, S. Ill, Dessau, 1781; Brandes, De Pectoris Paracentesi, Ocettingen, 1792; J. \j. Pei'IT, Traiie dc mal. chir,, already cited, 1774, T. I, p. 76. SiCCT. III.] THORACENTESIS, 573 Thoracentesis. — This operation was occasionally resorted to during tlie war to relieve the effects of effusions resulting from acute and chronic pleurisy; and, more frecpiently, on accjimt of effusions consequent on traumatic pleuro-pueumonia, or the lo^ment of foreign bodies within the chest. The instances that are not classified under other headings will be enumerated here. In the eight following cases, paracentesis of the thorax was practiced on account of hydrothorax or empyema unconnected with any wound of the chest: Case 1. — Private John Vaughan, Co. B, 3(1 battalion, 12th United States Infantry, aged 22 years, was admitted to the Post Ilos^iital, Washington, May 30th, 18C6, suffering from chronic pleurisy of the left side, with extensive effusion. By June 28th, the effusion extended over an inch above the left nipple. Good nourishing food, mercurial inunction, and mild diuretics had produced no diminution of the abdominal ffuid. The patient’s appetite was good ; he slept soundly, and was able to walk about, and felt but little inconvenience. Assistant Surgeon William Thomson^ U. S. A., performed paracentesis thoracis with a silver trocar above the ninth rib, near the inferior angle of the scapula, through valvular opening. Twenty-one ounces of albuminous serum were removed, after which the wound was hermetically closed. The operation was repeated .Tuly 16th, August 7th, and Sejitember 22d, giving but transitory relief. lie was returned to duty October 16th, 1866. Not a pensioner. Case 2. — Private Martin Carbit, Co. B, 18th United States Infantry, aged 23 years, was admitted to hospital at Camp Dennison, June 24th, 1864, suffering from empyema of left side. The symptoms present were an entire absence of tbe respiratory munmir of the affected side, with bronchial respiration, and protrusion of the intercostal spaces; fixedness of the thoracic parietes; tenderness on pressure of the intercostal spaces; dullness on percussion, and increased circumference of the side, relative to the noimal circumference of the other. There was also a small opening between the second and third costal cartilages at their junction with the sternum. On August 26th, the patient was very weak and life was fast ebbing away. His appetite was poor, and he suffered from diarrhoea, fever, and great dyspnoea. Acting Assistant Surgeon A. Buckingham introduced a canula between the sixth and seventh ribs; about one (ptart of thick pus of a very offensive odor flowed away. The operation was repeated on August 26th and 30th, and on September 1st, 3d, and 5th, the same ciuantity being drawn off each time, the pus becoming thinner. Stimulants and toiucs, with good, nour-ishing diet, were administered. The side collapsed considerably, and the patient’s strength improved rapidly. He was discharged from service September 6th, 1864. Not a j)ensioner. Case 3. — Private John H. Miller, Co. L, 17th Illinois Cavaliy, aged 20 years, was admitted to Marine Hospital, Chicago, Illinois, April 4th, 1864, with incipient phthisis and pleurisy, with effusion. Great dyspnma and cyanosis occui’i ed. On June 29th, Acting Assistant Surgeon Ralph N. Isham performed thoracocentesis. July 4th, jjatient walking about. Discharged from service July 28th, 1864. Not a pensioner. In the two following cases, metastatic abscesses and empyema appear to have resulted as pyaemic complications after excision or amputation for gunshot injuries of the extremity. There was no primary injury of the chest in either case: Case 4. — Private Robert Bivens, Co. E, 115th Illinois Volunteers, aged 20 years, was wounded at Chickamauga, Georgia, September 20th, 1863, by a musket ball, which passed directlj' through the right elbow-joint. On September 26th, Surgeon William Varian, U. S. V., administered chloroform and excised a portion of the right ulna and the inner condyle of the humerus. Simple dressings were applied, and tonics and stimulants, with nourishing diet, were administered. In February, 1864, inflam- mation of the lungs supervened, with formation of abscesses, for which paracentesis thoracis was peiformed by Dr. kloore, of Decatur, Illinois. The patient was discharged from service iSIarch 23d, 1865, on surgeon’s certificate of disability. Examining Surgeon Ira B. Curtis, Decatur, Illinois, August 14th, 1866, reports : “ Gamshot wound through arm near elbow-joint. There has been resection at the joint. .Joint was perfectly anchj-losed, and the wound still discharging at both orifices. Flextil .at right angle. Limb much emaciated and useless. General health poor, result of said wound, owing to the constant drain on the constitution. He was still a pensioner in March, 1872.” Ca.se 5 . — Private Seth T. Reynolds, Co. G, 4th Indiana Cavalry, aged 22 year.s, w’as admitted to Ilosjtital No. 1, Nashville, Septendier 3d, 1864, with a gunshot fracture of the three middle toes of tlA right foot and the metatarsal bone of tbe little toe of the left foot, received, accident, ally, at Nashville on the same day. Acting Assistant Surgeon M. L. Herr administered chloroform and removed the three toes of the right foot near the metatar.sal ])halangeal articulation, and also excised the fifth metatarsal bone of the left foot. On November 1st, 1864, Dr. Herr performed paracentesis thoracis of the left side of the chest between thesi.xth and seventh ribs, one-fourth the dist.ance from the spinal column to the sternum. Twenty ounces of pus were removed. The jtatient improved rapidly under the administration of tonics, stimulants, and nutritious diet, and, on December 21st, w.as transferred to Crittenden Hospital, Louisville; on June lOtb, 1865, to Brown Hospital, whence he was returned to duty, probally to be mustered out, June 14th, 1865. Surgeon B. B. Breed, U. S. V., imports the case. Three of the eight cases, in which tapping was resorted to on account of tlie. results of idiopathic pleurisy, terminated fatally: Case 6. — Private .John Robinson, Co. G, 112th Pennsylviinia Volunteers, aged 20 years, was admitted to Colivalescent Hospital, Philadelphia, February 24th, 1864, suffering from iileurisy of the right side, with effusion. By March 12th, the right 574 AVOUNDS AND INJURIES OF THE CHEST. [ClIAI-. V, thorax had become perfectl}’ Hat on pei’cussion. No respii-atory murmur could be heard. The sujierficial veins were distended and could be seen crossing over the surface. The intercostal surfaces were also distended. Tbe patient was in a sinking condition from want of due aeration of the blood. Pulse i:?2; respiration 48 per minute. Acting Assistant Surgeon A. U. Hall performed paracentesis thoracis, with bistoury and trocar between the sixth and seventh ribs, anteriorly, at the angle of the thorax. Twenty-four ounces of clear straw-colored serum were evacuated, wlien the flow was stopped, as the patient appeared exhausted. The dyspnoea was much relieved, but the patient was so utterly prostrated that ho continued to sink. The treatment, which had at lirst been especially du-eeted to the chest, was at a later period changed to supporting and stimulating. Death resulted March 13th, 1864. At the necropsy the right chest was found to contain twenty-four ounces of bloody serum. The right lung was compressed against the spine. The whole cavity was lined with thick, false membranes, and soft bridles of the same traversed the cavity in every direction. The ujiper lobe was consolidated. The left lung was merely hypostatically congested — floating in water. The wound of operation in the parietes of the right chest had healed over, making it difficult to be found on the inside. The heart was jierfectly healthy. Case 7. — Private William O. Martin, Co. E, 5th Michigan Cavalry, aged 19 years, was admitted to Jarvis Hospital, Baltimore, March 3d, 1865, suffering from pleurisy. Effusion and empyema supervened. On May 13th, the left pleural cavity was filled with a sero-pundent fluid, displacing the heart to the right side. Acting Assistant Surgeon H. McElderry performed paracentesis thoracis between the eightli and ninth ribs, on the left side; about two gallons of fluid were evacuated. Tonics and stimulants were administered. Death resulted May 27th, 1865. Case 8. — Private Thomas Tigner, Co. E, 193d Ohio Volunteers, aged 17 years, was admitted to Jarvis Hospital, Baltimore, March 27th, 1865, suffering with pleurisy and empyema. By May 29th, 1865, the right pleural cavity was distended with fluid, and there was great dyspnoea. Acting Assistant Surgeon E. G. Waters performed paracentesis thoracis between the eighth and ninth ribs, on the right side ; aboiii- one gallon of fluid was evacuated. The patient died June 22d, 1865. No doubt many other cases are noted on the medical reports, the subject strictly pertaining to the domain of internal pathology, and being mentioned incidentally only on the surgical returns.'^’ In the nine following cases, thoracentesis was performed on account of effusions following the perforation of the chest by small projectiles; Case 9. — Corporal L. G. Klanhowcr, Co. K, 1st Florida Regiment, was wounded at Mission Ridge, Tennessee, November 25th, 1863, by a nm.sket ball, which entered above the spine of the right scapula, passed through the cavity of the chest, and emerged one inch below the sterno-clavicular arliculation on the same side. He was taken prisoner and conveyed to Hospital No. 2, Chattanooga, December 8th. Anterior wound discharged daily; dullness over right lung in its whole extent; bulging of chest well marked. Percussion over left lung more resonant than natural. Upon forcibly distending the lung, about one pint of unhealthy jms was discharged from the anterior wound. Surgeon A. McMahon, 64th Ohio Volunteers, perfoimed thoracentesis at the lower angle of the scapula and upper border of seventh rib, drawing off at least sixteen ounces of sero-purulent matter, extremely fetid, jjresenting somewhat the appearance of dirty soap-suds. Wound closed with scraped lint. Anterior and posterior wounds closed with lint, firmly covered with adhesive plaster. The patient felt relieved after the operation ; the difficulty of breathing was not so great, but he was troubled with a short, dry, irritable cough. Stimulants were ordered freely. Death occurred on December 11th, 1863. Case 10. — Private George W. Sawyer, Co. A, Ist Michigan Sharp-shooters, was wounded at the Wilderness, Virginia, May 5th, 1864, by a conoidal ball, which entered a little below and to the right of the right nipple, passed through the lung, and emerged just to the right of the spine; the same ball also passed through the right arm. On June 14th, he was admitted to the Third Division Hospital, Alexandi-ia. Pleuri.sy and empyema supervened, and on January 25th, 1865, Assistant Surgeon W. G. Elliott, U. S. V., performed paracentesis thoracis. Tonics, stimulants, and nutritious diet were administered. The case progressed favorably, aud, on June 25th, the patient was transferred to Harper Hospital, Detroit, Michigan, whence he was discharged from service July 2l6t, 1865. Pension Examiner J. AV. Falley reports, September 1st, 1865, “the wound of entrance is still discharging. He is able to walk about the house.” Sawyer died July .30th, 1866. Case 11. — Private Owen Morrison, Co. I, 1st Ohio Volunteers, aged 22 years, received a gunshot wound of the neck and right shoulder by a conoidal ball at Resaca, Georgia, May 14th, 1864. He was treated in the fielil, and, on May 27th, was transferred to Hospital No. 1, Nashville, Tennessee. By June 17th, the jiatient was exhausted by coughing and labored respira- tioti, and the suffocation caused by a large collection of fluid in the chest. The intercostal spaces over the right side were obliterated, and the left lung was highly inflamed. Acting Assistant Surgeon H. C. May performed paracentesis thoracis of the right side of the chest, between the sixth and seventh i-ibs, five inches from the sternum. Ninety-three ounces of sero-purulent fluid were drawn off. The removal of the fluid gave temporary relief. Air reentered the collapsed lung. Tonics, stimulants, aud nutritious diet were administered. The patient died June 17th, 1864. from exhaustion. * The subject of thoracocentesis in the effusions of acute pleurisy has recently (April, 1872) been discussed at the Academy of Medicine of Paris, at great length. Professor BklllEH, in a memoir in which he claimed tlmt the popularization of tracheotomy in croup and thoracentesis in pleurisy were the two greatest of Trousseau's great titles to the grateful hom.age of the profession, supported the views advocated in the Clinique Midicale de VJJdtel- Dieu, by sixteen carefully observed cases, which he thought demonstrated the innocuitj' of “capillary thoracocentesis” with an aspirator providing against the admission of air. Many of the academicians joined in the exhaustive an2, says : “ (!e symptoine, qnc nous avons eu roecasion do oonstuter, est sans importance, et son apparition, toujours tariUve, s’ujonte rien au diagnostic sutlissamment 6lucide par le reunion d un certain noiiibru des symptomes (pic nous avons exjius^s.” 1 had concurred in the 576 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, lialf indu‘8 below the spine of the scapula, above the posterior margin of tjie arm-pit, by the teres muscles, and was found beneath the skin to the right of the sternum, beneath the fourth and fifth ribs. He rode about a mile and then fainted. The haemorrhage was considerable and he also vomited a little. Cold applications were applied and the patient was conveyed to Washington, entering Douglas Hospital on the next day. On admission there was extensive emphysema and distressing dyspnoea, the patient breathing with a peculiar puff of the mouth at every expiration. He complained of pain in the left hypochondriac region, in the vicinity of the ball, which was immediately extracted by a perpendicular incision an inch in length. The wound, of incision for the exit of the ball immediately gave rise to traumatic dyspnoea until it was closed with straps of isinglass plaster covered with collodion. The patient stated that he had considerable limmoptysis, perhaps a cup half full, immediately after having been wounded. Small doses of antimony and calomel, with stimulants, were administered, and an anodyne given at night. August 3d: Vomiting; bowels costive. A grain of calomel was given, which opened the bowels. Dyspnoea considerably diminished, but still annoy- ing; pain in left hypochrondriac region during cough was allayed by the application of a mustard poultice; emphysema the same as on the day before. August 4th: Appetite good; patient somewhat more comfortable. On the 5th, the anterior wound was opened, which seemed to ease his respiration for a short time, but the distress in breathing soon I'eturned. The patient recognized the extent of his injury and had no hopes of recovery. August 6th: The patient passed a tolerably good night; dyspnoea increased during t;he course of the day ; emphysema in lumbar region ; a mild cathartic was given ; the cough became more troublesome and painful. The patient vomited a bilious green fluid, and during that act a '‘paracentesis naturalis” occurred by the violent explosion of the adhesive plaster from the anteilor wound, followed by the discharge of a pint and a halt of bloody serum and hot blood, which escaped particularly rapidly at each expiration and effort to cough. This escape of the bloody effusion in the thoracic cavity relieved him from the annoying dyspnoea, but weakened him in a great degree. Stimulants were adnnnistered freely, but he gradually sank ; the arterialization of the blood could not take place; the blood became poisoned by carbonic acid, and he died of coma at 11 o’clock P. SI., August 9th, 1863. A post-mortem examination was made ten hours after death. A strong, well-built, robust cadaver; excellent physique. Stiffness of death well marked. Emphysema all about the upper portion of the sternum and both sides of the chest. The back and left thigh were of a mulberry hue. The pistol ball had perforated the inferior edge of the shoulder- hlade, just below the glenoid cavity and the infraspinatus and subscapularis muscles. It went into the left thoracic cavity, between the second and third ribs, and penetrated the anterior portion of the upper lobe of the left lung, and, extending across the chest above the blood vessels, entered the lower portion of the upper lobe of the right lung. A perpendicular incision one and a half inches obliquely upward from the right nipple, between the third and fourth ribs, an inch external to the sternum, represented the wound of exit. On removing the isinglass plaster which closed this wound, a considerable rush of air escaped. On careful dissection of the skin, the cervical, pectoral, and abdominal muscles were found largely infiltrated with blood, and there were clots of coagulated blood between the cellular tissues. The right lung was completely collapsed, caused by one-half gallon of blood in the pleural sac; nearly the same condition on the left side. Adhesion of both lungs to costal parietes indicated late pleurisy and the cause of former pain in that region. The heart and its appendages were normal. Paracentesis thoracis was performed between the eighth and ninth ribs on the right side, posteriorly, without injuring the lungs, and it gave exit to the enormous quantity of extravasated blood. The case is reported by Acting Assistant Surgeon Carlos Carvallo. The specimen, numbered 1680 in the surgical series of the IMuseum, is the left scapula, grooved just below the glenoid cavity. A fissure of one inch and a half, not connected with the direct wound of the ball, exists in the lower wing of the bone. The preparation and the notes of the case were forwarded by Assistant Surgeon Wm. Thomson, U. S. A. view expressed by Dr. Fraser, at page 87 of his often cited work, and supposed that this sign was admitted by surgical authorities chiefly through deference for the great name of Darrej-. Dr. Fraser says: “The presence of the ecchymosis of blood in the loins * * which I never witnessed, altliougli it is dwelt upon as certain evidence of effusion into the pleural cavity, by Valentin and others, * * * indeed, if it were not for the distinct statement made by Baron Laivey, at page 240, as to the presence of this peculiar discoloration, ‘ce signe est I'nn des plus pathognomoniques,' I sliould consider this as one of many matters of romance, unthinkingly handed down by one writer to another.” Larre}' appears, however, to dwell more upon the (edematous engorgement, that Valentin also regarded as characteristic, than upon the ecchyraotic discoloration. Here is the passage from the Clinique. Chirurgicale, T. II, p. 240: “Enfin Ton aper(;oit, ainsi que I'indique Valentin, nn engorgement ceeUmateux plus ou moins 6tendu, avec on sans ecchymose, derridre I’hypocondre correspondant & repanchement, et ce signe est Vun des plus pathognomoniques. II se produit par une sorte d’infiltration sdro-sanguine qui se fait du foyer de I'dpanchement, a travers les membranes sdreuses, les muscles intercostanx et dorsaux, les tissus cellulaire et dermoide. Nous avons cemstamment observe ce phenomene, et nous avons plusieurs fois snrpris la nature dans la marche de sa formation, e’est-a-dire qu’d rouverture des cadavres des personnes mortes de ces blessurcs avec dpanchement, nous avons pn suivre I'infiltration sanguine depuis sa source jusque sous la peau." With this testimony, the subject would appear to demand further investigation. I will append one more citation from Valentin's rather rare book (Hecherches critiques sur la Chiritrgie woderne. Amsterdam, 1772, p. 72j, that the nature of the signs he insisted on may he precisely understood: “Ces caracteres ne se recontrent point dans rdchiniose qui est le signe de repanchement de sang dans la poitrine : celle-ci en a d’antres qui lui sont absolnment propres; dans quelque point de la circonf6rence de la poitrine que suit la plaie, cette Schimose est tonjours situ6e dans le meme lieu, du cot§ od repanchement existe : elle se forme vers I’angle des fausses cotes : elle prend sa direction vers le carrd des lombes ; on I’observe souvent d la surface de ce muscle : sa couleur est la meme que celle des taches qui paroissent au bas-ventre peu de terns apres la raort, e’est d dire, d'un violet tres dclairci; d'ailleurs ce signe ne se manifeste point dans le premier instant, on ne I'appecoit ordinairement que deux jours ou environ apr6s I’accident; il est quelquefois plus longtems sans se rendre sensible. On con<;(tit ais6ment que I’on ne pent attribuer cette 6chimose qu’d I’infiltration du sang 6panch§ ; la partie la plus fluide de cette li(iuenr, apres avoir p^nfetre la plevre dans le point le plus diclive de la poitrine, dchappe sans peine aux digitations que ferment les attaches du diai)hragme.” “ Ce n'est pas sdulement dans les epanchemens de sang cpie I’on pent observer cette espece de suintement de I'humeur contenue dans le poitrine; il a figalement lieu lorsqn'il se fait, dans cette cavitd, un amas d'eau et de pus. Quoiqu'il n'entre pi.int dans uion plan de trailer iei des signes de ces deux especes d'eiiauchemens, cette seconde v§rite vient si natnrellement a I'appui de celle (ine j’ai deja etablie, elle est d'ailleurs si importaute par elle-meme, que je n'ai pas cm devoir la passer sous silence.” — COMI'ILEU. Sect. III.] THORACENTESIS. 577 Case 15. — Private Ellis Hulzizer, Co. G» 36th Illinois Volunteers, aged 18 years, was wounded at Dallas, Georgia, May 30tli, 1864. The missile entered the left side, in front, passed through the pectoralis major muscle, near its tendinous jjortion, fractured a rib, perforated the thorax, and emerged behind, having perforated the scapula. He was at once conveyed to the hospital of the 2d division. Fourth Corps, where simple dressings were applied. On August 1st, he was admitted to Hosj)ital No. 19, Nashville. The patient was irritable and prostrate, and suffered from fever, diarrhoea, and much emaciation. On August 15th, the wounds of entrance and exit were open, but being so high in the thorax there was a large amount of pus constantly accumulating in the pleural cavity, and it was deemed expedient to make an opening at a lower point to allow ready drainage. The lung was completely collapsed, and the discharge very offensive. Acting Assistant Surgeon Charles S. Merrill performed paracentesis thoracis, the opening being made between the sixth and seventh ribs. A tube was introduced and retained, the pleural cavity being cleansed, daily, with tepid watei', followed by a weak solution of chlorinated soda for its stimulating and disinfectant qualities. Generous diet, with a liberal allowance of tonics and stimulants, was given, with vegetable astringents and opiates for diarrhocal discharges. Death resulted on November 2d, 1864, from exhaustion. The three following of the series of nine shot perforations of tlie chest are reported as instances of partial recovery : Case 16. — Captain Noah Bowman, Co. D, 142d Pennsylvania Volunteers, aged 28 years, was wounded at Petensburg, Virginia, April 1st, 1865, by a conoidal ball, which entered one-fourth of an inch to the left of the ensiform cartilage, passed beneath the ribs, through the right lung, and emerged at eighth rib, below axillary space. Ilmmoptysis followed, which lasted for several hours. He was treated in the field hospital of the Fifth Corps until April 29th, when he was transferred to Armory Square Hospital, Washington. When admitted, the patient suflered greatly from dyspnoea ; characteristic sputa of pneumonia; lower lobe of right lung collapsed; considerable febrile movement ; great emaciation. May 6th : Upon a careful examination, the succussion sound was distinctly heard ; the line noting the height at which the fluid stood, while the patient was in an upright position, was about two inches above the right nipple. As both wounds were closed, an incision, of a valvular nature, was made near the wound at eighth rib, and a No. 7 gum-elastic catheter introduced about four inches into the cavity, pointing downward, when, by means of a Davidson’s syringe, sixty-eight ounces of pus and serum, having an exceedingly ofl'ensive odor, was withdrawn. The catheter was then removed and the integument held firmiy over the opening by the atmospheric pressure, thereby preventing any ingress of air from without. Very little pain attended the operation, and the patient expressed himself as feeling greatly relieved. lie improved rapidly in health, and, on May 2Gth, left for his home with good use of right lung and in an apparent condition for a complete and speedy I'ecovery. He was discharged from service on June 1st, 1885. Pension Examiner Henry Brubaker reports, November 10th, 1865, that there is constant and free discharge of pus from the opening iii the right side of the chest. The right lung is almost completely consolidated. He is entirely unable to leave his room. Greatly emaciated and debilitated. Still on the Pension List in 1872, — no improvement reported. . Case 17. — Sergeant Hiram H. Terwilliger, Co. E, 80th New York Volunteers, aged 29 years, was wounded at Bull Run, Virginia, August 30th, 1832, by a minie ball, which struck just below the calf, on the inner side of the left leg, and split upon the bone, one part passing through and issuing near its point of entrance; the other lodging on the outer side of the leg. This wound bled freely and occasioned considerable pain, but he kept his place, till, as he thinks, about a half hour later, when he was struck again by a round bullet on the left side ; the missile passed directly through the cavity of the chest, grazing the lungs and liver, aiul emerged between the seventh and eighth ribs on the right side. It then entered the right arm and fractured the humerus into the elbow joint, where it lodged ; the spiral nerve was injured. - The first stunning sensation of the wound having passed, he left the field and walked a distance of about two miles, when, exhausted by loss of blood, he fainted. He was con- veyed to Alexandria, and admitted, on September 1st, to Fairfax Street Hospital. On admission, he was insensible!. Strong stimulants were administered. Acting Assistant Surgeon Robertson removed the half of the ball which had loilged in the leg ; it was found flattened and ragged-edged. The case progressed favorably for about eight weeks, when the wound of the chest closed. This was followed by diarrhoea and feverishness, which symptoms passed off in a few days. His appetite and Hesh returned, and lie was discharged from service on January 14th, 1833. Soon after his arrival home, a cough set in, followed by severe pain in left side, disturbed sleep, impaired appetite, laborious breathing, swollen limbs, night sweats, and profuse expecto- ration. These symptoms becoming more and more aggravated, and evidence of pus in pleural cavity being well defined, the operation of thoracentesis was performed by Dr. Smith Ely, of Newburgh, New York, on April 28th. A trocar was plunged into the cavity of the chest, just below the left shoulder blade, and an India-rubber tube inserted in the opening, the ends of which were left hanging down about four inches, the one within and the other on the outside of the chest. The operation was painful in the extreme, but, weak and emaciated as he was, he endured it without flinching. No ancesthetic could be administered, owing to his feeble condition. Through the syphon formed by the tube, there was discharged, during the ensuing ten days, about seven quarts of matter. At the end of that time, the tube was removed and the opeiung immediately closed. The heart, which had been pushed around to the right side, resumed its natural position, and the lungs their proper functions. The cough ceased, swelling disappetired from his limbs, and his health gradually improved, until about September 1st, when he removed to Alexandria, Virginia, and went into business. I’ension Examiner R. Loughran reports, October IGth, 1871 : Adhesion of i)leura and difficulty in expansion of chest and respiration. Almost constant pain in track of ball. Digestion greatly im()aired, and general debility of the entire system. Partial anchylosis of elbow-joint. Tibia injured and soft j)arts consolidated ; partial loss of motion of foot.* Case 18. — Private Keefe, 14th Uiuted States Infantry, aged 21 years, while running the guard at Fort Trumbull, Connecti- cut, received three gunshot wounds, the missiles being buckshot. Two of the latter entered his legs, inflicting mere flesh wounds, while a third struck a rib, one inch beneath the angle of the left scapula, and coursed around the chest, and to the left, tin: length * This case was reported, at great lengtti, in tlie Proecedings of the Ellenville (Ulster County, New Y(jrli) Historical Society, .July 8th, ISlit, and 16 copiwl in the Medical and Surgical Reporter, Philadelphia, 18ti5, Vol. XII, p. 137. 578 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, of a probe ; its subsequent direction and position being doubtful. Tito shock to the system was marked and resulted in much depression. A slight cough commenced on the following morning, with bloody expectoration, both of which continued for three days and then ceased. This, in connection with a slight emphj’sematous condition of the cellular membrane, in the neighborhood of the external wound, indicated a probable injury of the lung. Auscultation and percussion failed for some time in announcing pathological changes, and, with the exception of a severe periodical cough, coming on every evening and lasting half an hour, there was nothing to cause suspicion of the approach of pleurisy, respiration being natural and the patient able to lie, fi-om the first, on either side and in a horizontal position. Rest, rigid diet, and mild antiphlogistics, with morphia for the paroxysmal cough, were alt the medication which he received at the outset. Though his countenance did not recover its accustomed hue and healtlifulness, yet his appetite being good from the first, and there being no cough and but little, if any dyspnoea, he was sent to quarters. Subsequently, physical examination detected a gradual effusion into the left cavity of the chest, which increased ultimately until the heart pulsated three inches to the right of the median lino of the sternum. So gradual was its occurrence, that the opposite lung had been akle perfectly to adapt itself to its increased and supplemental duties, and decubitis on either side, with the head low, was perfectly easy and without cough. The treatment consisted in large blister, frequently repeated, the use of squills, digitalis, and calomel, and, subsequently, hydragogue cathartics and iodide of potassium. Owing to unsusceptibility of the system to the actioti of mercury, its specific effects could not be produced by careful medication, and hence probably a ground of failure. Although there was no imperative symptom demanding an ojieration, yet, as the presence of effusion was so cleai ly indicated by stethoscope and other symptoms, it was thought advisable to operate, which was done substantially after the manner of Wyman and Bowditch, using a small exploring trocar, but in connection with the stomach-pump furnished army surgeons, in ])lace of the more complicated instrument invented especially for this purpose. The resistance being considerable and the trocar delicate, it could not be forced in rapidly for fear of breaking, and the pleura was evidently pressed before the needle, and, although ultimately punctured, yet, from some cause, the orifice in the canula became closed after about six ounces of bloody serum had been discharged. The relief was, however, marked and permanent ; respiration was deeper, vocal fremitus increased in extent, the heart in some measure receded to its accustomed position, and the patient became, in all respects, improved. Diur- etics and hydragogue cathartics had an increased power, and within a fortnight after the operation there were some two m- three j)ints of serous matter discharged apparently by fistulous opening into the bronchi. He constantly improved in health, and at his own suggestion was returned to garrison duty. In June, 18G3, this man’s chest was carefully examined, and the lower half of the left lung found dull on percussion, no vocal fremitus, and the heart pulsating a little to the right of the sternum; Not a pensioner. Acting Assistant Surgeon Isaac G. Porter, the operator, reported the case.* This man accompanied a detachment of his regiment to Madison Barracks, whence he deserted on September 18th, 1863. In the four following cases, hydrothorax or empyema followed the lodgment of missiles in the chest, and tapping was employed as a palliative measure ; the first three ended fatally, the last was a partial recovery; Case 19. — Corporal J. Kelly, Co. B, Gth Wisconsin Volunteers, was wounded at the battle of Gettysburg, Pennsylvania, July 3d, 1863, by a musket ball, which entered the chest and lodged. He was treated at the hospital of the first division. First Cori)s. Paracentesis thoracis was performed by Surgeon A. W. Preston, Gth Wisconsin Volunteers, fifteen days after the recep- tion of the injury. Death followed on the 21st day of July, 1863. Case 20. — Private Philip Carpenter, Co. I, 4th Michigan Volunteers, aged 22 years, received a penetrating wound of the chest at Cold Harbor, Virginia, June 3d, 1884. A conoidal ball entered four inches below the outer third of the left clavicle, over the third rib. He was taken to the hospital of the 1st division. Fifth Corps. There he remained until the 12th, when he was transferred to Douglas Hospital, Washington. On admission, there was a large effusion into the left thoracic cavity, extreme debility, and dyspnoea. Assistant Surgeon William Thomson, U. S. A., performed paracentesis thoracis; seventy-two ounces of bloody serum were evacuated. The canula was allowed to remain, and during the night there was a free discharge. He spat dark blood at first, then pneumonic rusty sputa. Death resulted June 22d, 1864, from traumatic pleuro pneumonia. At the necropsy, the lungs were found to be hepatized. There were fifty ounces of fluid in the thoracic cavity. Evidences of pericarditis were also found. Case 21. — Private Thomas Kinney, Co. A, 17th United States Infantry, aged 36 years, was wounded at Petersburg, Virginia, September 30th, 1864, by a ball which entered under the inner third of the clavicle, one inch from the margin of the sternum, fractured the second rib, and lodged in the right lung. He was conveyed to the hospital of the Fifth Corps, and on October 7th was transferred to Harewood Hospital, Washington. When admitted, his constitutional condition was good. On October 11th, hoemothorax was diagnosed. The right lung was compressed, there was dullness on percussion, an absence of the respiratory murmur, and dyspnoea. Surgeon R. B. Bontecou, U. S. V., administered ether and performed paracentesis thoracis on the right side, between the sixth and seventh ribs, in the linea axillaris ; five quarts of blood and serum were removed. The patient felt much relief after the operation, respiration becoming easy and audible through the whole of the right lung, except in the inferior part of the third lobe. The wound was covered with oil-silk to prevent the admission of air, and a DoveFs powder was given eveiy three hours. The case progressed as follows ; October 12th, pulse 120. October 13th, feels pretty well ; pulse 90 ; respiration audible as before. The wound discharged a bloody serous fluid. At 6 p. m., re.spiration was difficult, and percussion in the lower parts dull ; respiration was not audible on the posterior side. The finger was introduced into the opening and a large amount of bloody serum discharged ; the patient felt somewhat relieved. October 14th, weak ; pulse 110; discharges free and of a putrid smell ; crepitation. Percussion dull in lower part of left lung; respiration normal. Treatment, supporting; Dover’s powder of ten grains every three hours. The patient continued to sink, and died October 20th, *POUTEI!, I. G. — Cases, in Jour, of the Med. Sciences, N. S. Vol. XI, VII, p. 13.5. Sect. III.] TIIOEAOENTESIS. 579 18G4, from exhaustion. At the autopsy, ten hours afterward, both auricles, and the riglit ventricle of the heart, were found to he filled with fibrinous coagula. The pericardium contained a small quantity of scrum. The right lung was collapsed and hepatized ; the bronchi and their ramifications were filled with matter. The ball entered the inner margin of the middle lobe of the right lung and emerged on the exterior surface of the third lobe, slightly fractured the eighth rib, and was found lying on the diaphragm. The pleurae were covered with lymph, and a spicula of the second rib was found. There were a few small tubercles at the apex of the left lung. Case 22. — Private D , 40th Illinois Volunteers. Gunshot wound ; ball entered right thorax ; extensive emphysema followed. Paracentesis-thoracis performed. The patient recovered sufficiently to be discharged from hospital. The case is reported by Surgeon E. Andrews, 1st Illinois Light Artillery. In two cases, in which paracentesis of the thorax was unavailingly performed, traumatic pleurisy, with effusion, followed gunshot wounds of the chest that apparently did not penetrate the pleural cavity: Case 23. — Sergeant J. B. E , Co. D, 30th North Carolina Eegiment, aged 19 years, was wounded at Kelly’s Ford, Virginia, November 7th, 1863. The ball entered fo\ir inches to the right of the spinous processes, between the tenth and eleventh ribs, and emerged between the eighth and ninth ribs, in a line with the middle of the axilla. The eighth and ninth ribs were fractured near the wound of exit. The track of the ball was five inches long. He was taken prisoner and conveyed to Wash- ington, entering Douglas Hospital on the 9th. The wound was considered a non-penetrating one, although the jjatient stated that he had coughed some florid, frothy blood, and had suffered from dyspnoea. His expectoration was slightly tinged with blood for several days after his admission. The wound discharged freely, and became very tender on pressure. A harassing cough and increasing dyspnoea indicated the presence of traumatic pleuritis. The treatment comprised diuretics, expectorants, with sedatives to procure sleep, tonics and nutrients, with stimulants, and iodine locally, in form of tincture, over the chest, as a counter-irritant. Acting Assistant Surgeon Carlos Carvallo, who reports the case, says: “At four and a half o’clock a. m. of December 8th, he awoke suddenly from a dream, very much frightened, coughed very hard, and expectorated freely an enormous quantity of remai'kably thin, mucous, very frothy phlegm. At nine o’clock A. M., I found him exceedingly collapsed, though feeling himself, subjectively, very well — he thought he was strong. On examining his chest, I found a great deal of effusion in right chest, whizzing in the bronchial tubes, and some dyspnoea. After considtation, paracentesis thoracis was decided uj)on, and Assistant Surgeon William Thomson, IT. S. A., introduced a trocar into the posterior lateral angle of the right chest, between the tenth and eleventh ribs, which was followed immediately by the exit of thirty-eight fluid ounces of pus. The operation was unaccompanied by pain and produced almost instantaneous relief from the dyspnoea. The whizzing also diminished to a great degree. Stimulants were freely administered. In the afternoon, the patient appeared to be in a moribund state, but toward night he rallied considerably and felt comparatively comfortable. He passed a restless night, though he breathed easier than before the operation. At seven and a half A. M., he said he felt strong and hopeful, but he died at quarter to ten o’clock A. M., December 9th, 1863.” Necropsy: Several patches of ecchymosis in the intercostal muscles, between the ninth and tenth and eleventh and twelfth ribs. Eight lung collapsed and shrunk up, and adherent to costal parietes of pleura. Left luug congested — otherwise normal. No signs of pneumonia. The pleural leaf which covered the internal surface of the right chest was exceedingly thickened and presented the appearance of leather. The pathological specimen, showing the anterior portion of the eighth rib on the right side fractured, with splintering of the internal surface, is No. 1901 of the Surgical Section, Army Medical Museum. A moderate osseous deposit has occurred. It was contributed by Assistant Surgeon W. Thomson, U. S. A. Case 24. — Corporal Israel Spotts, Co. G, 200th Pennsylvania Volunteers, aged 24 years, received a gunshot non-penetra- ving wound of the chest at Petersburg, Virginia, March 2f th, 1865. He was conveyed to the hospital of the Ninth Corps, where haunoptysis and dyspnoea supervened. On April Cth, he was transferred to Harew’ood Hospital, Washington. Surgeon E. B. Bontecou, U. S. V., reports that the ball entered the back in the dorsal region, about two inches below the spine of the scapula, and buried itself in the ti-apezius muscle, whence it was extracted. On admission, the condition of the injured parts and consti- tutional state of the patient were good. He did very well for a while, the wound healing kindly ; but toward the early part of the mouth of May, the chest became enormously distended with effusion. There was a harassing cough, anxiety of countenance, oppressed breathing, and symptoms of empyema. An operation being necessary to relieve the patient, paracentesis thoracis was performed by Surgeon Bontecou, on May 9th, by freely opening the chest at the right posterior and lateral aspect, between the eighth and ninth ribs. About six pints of sanious pus were removed; no anmsthetic was used. The patient felt at once relieved and did remarkably well after the operation. The treatment consisted of simple dressings, anodynes, and supporting throughout. He was furloughed and sent to his home at Hammondstown, Pennsylvania. Dr. Stichley, attending physician, states : “Saw soldier after he reached home; found him suffering from empyema. After he was home a few days an operation was performed on him, removing two or three quarts of pus from his chest. Operation had to be performed every two or three weeks. The bullet was still in the lung. He lived in this condition for about two months. Death resulted September 20th, 1865, from exhaustion produced by suppuration.” On page 449, a complicated case of tapping for empyema is recorded; another case, attended by pneumothorax and empyema and treated by free incision into the thorax posteriorly is noted on page 493 ; an instance in which the diaphragm and liver were perforated in tapping is reported on page 504; and a case in wliich fluid, tinged witli bile, was removed from the pleural cavity by paracentesis is referred to on page 513. Adding 580 WOUNDS AND INJUKIES OF THE CHEST. [Chap. V, these to the twenty-four foregoing abstracts, a total of twenty-eight cases of thoracentesis is presented, with nine recoveries. Abstracting eight cases of effusion from idiopathic pleurisy, there remain twenty instances of tapping for effusions in the chest following injuries, with only four recoveries, a death rate of 80 per cent., indicating that the ordinary mortality of penetrating gunshot wounds of the chest is not materially affected by the operation. The side on which paracentesis was performed is indicated in twenty-five of the twenty-eight cases, and was on the right in fourteen, and on the left in eleven cases. Whether any significance should be attached to the fact that in twelve of the seventeen determined fatal cases the operation was performed on the right side, the figures are too few to decide. Drainage Tubes .^' — In some of the cases of empyema, discharge from the pleural cavity was facilitated by the employment of drainage tubes, with the instruments and method so much insisted on by M. Chassaignac, or by using an ordinary gum catheter as a syphon. An ingenious plan of keeping apart the lips of sinuses, which it was desirable to have pervious, was in common use at Armory Square Hospital, and was devised, I believe, by that excellent surgeon. Dr. G. K. Smith, of Brooklyn. It consisted simply of a bent watch- spring, of the form indicated in the wood-cut (Fig. 275), with sufficient elasticity to separate the walls of long fistulous tracks in the soft parts. In suppuration in the thick muscles of the thigh or calf in compound fractures, this simple expedient was found far preferable to any form of tent or drainage tube, and it could be used advantageously in sinuses on the anterior aspect of the chest and abdomen. The utility, in cases of thoracic fistulae of keeping the pleural cavity as far as possible, free from decomposing fluids, was universally acknowledged. The following is a case in which a tube was inserted daily. Frequently they were left in place permanently: Case. — Private Gotlieb Blesserij, Co. G, SOth Ohio Volunteers, aged 20 years, was wounded at Mission Eidge, Tennessee, November 25th, 1863, by a musket ball, which entered just below the left clavicle and passed out posteriorly, fracturing the inferior angle of the scapula. He was taken to the hospital of the 3d division. Fifteenth Corps, where he was treated until December 22d, when he was transferred to the general hospital at Chattanooga. At the time Fig. 275.— Watch-spring dila- of admission he was breathing rapidly and with great difficulty. On a physical examination tor for sinuses. ,S/>cc. 2455. of the chest, found the diaphragm forced down and bulging of the left intercostal spaces; the heart to the right side of the sternum and general dulness over the left side of the thorax. Change of position had no influence over the sounds elicited by percussion ; no respiratory murmur could be discovered on the left side ; that of the right was increased and sibilant. The pul.se was frequent and weak. Appetite poor. Wounds of entrance and exit discharging small quantities of reddish pus. On the second day after his admission a small tube was passed through the iiosterior wound into the pleural cavity and about twelve ounces of pus drawn off. After this the tube was inserted daily, and largo qu.antities of thin foetid pus withdrawn. After the fluids were removed, tlie left side of the thorax became much contracted and the heart resumed its normal position. Tonics, stimulants, and anodynes were administei'ed. The patient gradually sank, and died ou January 11th, 1864, from exhaustion. Necropsy: Fifth, sixth, seventh, and eighth ribs fractured. Fragments of bone protruding in thoracic cavity. No attempt at repair. Base of heart opposite upper border of third rib ; apex opposite intercostal space of fifth and sixth ribs, two inches from median line. Pericardium thickened and containing one ounce of straw-colored serum. Left lung compressed against spinal column, and occupying a space five inches in length and one and a half in width. The remainder of the thoracic cavity was occupied by an abscess emptied of its pus but containing twelve ounces of bloody serum. * See M. IIOLON, Du traitement de Vempyime purulent par le drainage chirurgicalc, 187G, These de Paris, 141. This author has collected many favorable cases from the practice of M. Chassaignac, and Drs. Goodfellow, Banks, Fincham, and other English practitioners. See also M. Chassaignac, Traiti pratique de la Suppuration et du Drainage chirurgicale, Paris, 1859, T. II, p. 34C ; also Drs. FULLEK, H. W., POWELL, D., and PLAYFAIR, in British Medical Journal, 1872, February 17th, p. 183, and March 3Cth, p. 339, and Dr. Powell, in Clinical Soc. Transactions, Vol. HI, p. 244 ; Dr. Maclagan {Brit. Med. Jour., July 2Cth, 1872, p. 63). Mr. DeMougan {Med. Chir. Trans., 1859, Vol. XIJI, p. 231) speaks favorably of the results of drainage in empyema at the Middlesex Hospital. Surgeon D. 1’. Smith, U. S. V., advocated the treatment at the beginning of the war {Am. Med. Times, •July 6th, 1861, p. 13), but has not recorded any observations, that I can find, of later experience. Sect. III.] THORACENTESIS. 581 Jncisiom, Injections . — Rurgeons Bontccou/ Ilainilton,® IToward/' Ellis/ and otlioi’s, advised or had recourse to free incisions into the jdenral cavity in some cases of traumatic empyema, especially those complicated by the presence of foreign bodies or of coagula of blood. Personally, I am convinced that this is, under certain restrictions, sound practice; but I am unable to adduce any instances that testify, in a striking manner, to its efficacy. The cases that came under my observation were benefitted, I believe, by this interference; but they were not cured; and nearly all of those referred to by writers on this particular point were of such a character as to admit only of palliative measures."'^ The utility of injecting stimulating fluids into the pleural cavity after jun’ulent effusions had been evacuated and a permanent drain established, was advocated, but not acknowledged. The advantages of M. Boinet’s method” were not realized. Surgeon F. H. Hamilton^ advised, in cases complicated by the presence of foreign bodies in the cavity’ of the chest, thorough syringing, “with such disinfectants as carbolic acid, chloride of soda, or bromine;” but no evidence of their efficacy is produced. Tepid detergent injec- tions, to wash away foul discharges, and occasionally bits of clothing or of exfoliated bone, and warm milk and water, as recommended by Guthrie [Comm. 1. c., p. 429), was found as unirritating and useful as anything. The advantage of the suggestion of this admirable teacher to have the opening, in these cases, as low as possible, was appreciated; though most surgeons did not venture on the eleventh intercostal space behind, as advised by him, the tenth intercostal space being considered as low a point as was consistent with the safety of the diaphragm. The point of election for the first puncture, though in a measure determined by the seat of injury and the nature of the effusion, appears to have been the seventh intercostal space, one-third of the distance from the spinous processes of the vertebra to the median line of the sternum. This point was selected in nine of seventeen cases in which this particular is noted. In five, the puncture was made between the eighth and ninth ribs, and once in the fourth, once in the fifth, and once in the tenth intercostal space. The ordinary trocar, finnished in the field operating cases, was usually employed; but, in a few instances, the methods and apparatus recommended by Drs. Wyman and Bowditch,® and by Dr. Flint were employed.” *Dr. BONTECOU, ante, p. 493; ^iiAiilLTON, rrin. and Tract, of Sure/., p. 70:2; ^Howakd {/. c.), (i\T 3'. Med. Jour., Vol. XIV., p. 511). ®HirPOCiiATES, according to Haller, sanctions paracentesis of the chest in einpj’ema, by boring through a rib, in the treatise nepi twv cvtos naOoiu. Leonides taught that the thorax might be opened between the fifth and sixth ribs to remove pus, though he, or I’aul LA.NN, a militarj’ surgeon of Breslau, whom Percy accredits ns the first to practice thoracentesis, advocates the operation in his Chirurgischer Lorherkranz, Oder grosse Wundartzneg (Halberstadt, 1U85, Frankfort, 1692, Breslau aiul Lcipsig, 1705), and, in the last edition, cites a successful case of thoracentesis, for traumatic effusion of blood and pus. After him Aliunus, Veuduc, BnUNNEK, Petit, and Valismeui, refer to paracentesis in empyema, with approbation. On the applications of the oixTution in military surgery, some- thing may be found in Ravaton (TVaiTc des Playes des Armes a Feu,VQ.ns,\loO)‘, Gauengeot (TraiU dcs Op. Paris, 1748); llEiSTEil (Instit. Chir., Amsterdam, (1739), and in PEltCV (loc. cit.)-, in Laeuey (Mem. de chir. mil.. Paris, 1812, T. Ill, p. 442) ; in IIennen (Mil. Surg., 3d cd., 1829, p. 382); and in GutiihiE (Comm. p. 424). ®M. Boinet, Traitement des epanchements pleuretiques imrulents par les Injections en general et Ics Injections iod6es en particuliev, in Arch. g6n. dc Med., 1853, 5e S.^ T. I, pp. 277, 521. ’Hamilton, F. H., The Prineijiles and Practice of Surgery, 1872, p. 112. ®Bowditch, H. I., On Pleuritic Ejfusions and the Neces.%ity of Paracentesis for their liemoval. Am. Jour, of the Med. Sci.j Vol. XXIII, p. 320. ®RUST (Theoretisch-praktisches Uandbuch der Chirurgie, Berlin, 1834, p. 57) advises to incise midway between the sternum and spine, at the upper margin of the last rib, to avoid the main branch of the intercostal artery, but unless the operator is well satisfi<*d that the diaphragm is miu’h dcpressereparation, which submerged in .alcohol by its own density. It was not a fragment of the larger ball, which, though battered and flattened by imjiact on tbe first rib, was entire and weighed 540 grains. Its presence in the already perplexing specimen was very puzzling. FiG.t287. — Ball ludgcd against pulmonary vein. Spec. *d388. Sect. 1, A. M. M. Fig. 288. — Ball and fragment of ball removed from Spex. 3888. Fig. 2811. — Thickened and adherent pericardium and portiiai of left lung, ivith imbedded ball. Spec. IITIKI, Soot. I, M. M. Case 18. — Priv.ate Alexander J , Co. K, C2d Ohio Volunteers, aged 33 years, was wounded at Deep Bottom, Virginia, August IGth, 18G4, by a mini6 ball, which penetrated the right side of the thorax near the sternum. He was t.aken to the field hospital station of the 1st division of the Tenth Corps, where the wound was dressed and a chest bandage applied; and restoratives given. He was very faint and the breathing was labored. He was sent to City Point, and placed on the hospital transport Connecticut, in charge of Surgeon T. B. Flood, U. S. V., and conveyed to Philadelphia. On the 21st, he was admitted to the hosjiital .at Beverly, New Jersey. Cold-water dressings were applied to the wound. He died December 21st, 18C4, from empyema of the left side. At the necropsy the ball was found to have entered just above the sterno clavicular articulation of the right- side, passed downward and to the left, fractured the sternal end of the left clavicle, and, entering the chest, imbedded itself in the left lung, where it was found. The left pleur.al cavity contained about two quarts of pus, which compressed the lung so as to cause solidificatioli of that organ. The pericardium was firmly adherent to the heart, and the liver and spleen were some- wh.at enlarged. The other organs were in a healthy condition. The adjacent wood-cut (Fig. 289) shows a wet prep.aiation of the heart and left lung, with the model of a conoidal bullet in situ. Assistant Surgeon Woodhull remarks that “tbe specimen shows that neither speedy death nor pneumonia is a necessary consequence of gunshot wound of the lung,”* but the evidences of pulmonary as well as cardiac inllammation are unmistakable, though the fatal issue was so long delayed. The preparation was contributed, with a history of the case, by Assisfant Surgeon C. Wagner, U. S. A. * CnUdngue of the Surgical Section of the Army Medical Museum, 1808, p. 480. As leaden bullets in wet preparations rapidly oxidize anil discolor the aleobol. I commonly replace them with a cast painted witli dark insoluble varnish, and preserve the missile outside tbe jar. — CUKA'I'OK. Sect. III.] BALLS AND FOREIGN BODIES LODGED. 589 Case 19. — Private J. J. P , Co. B, 5th Wisconsin Volunteers, aged 24 years, was wounded at Cliancellorsville, May 3d, 1863, by a conoidal ball, which entered between the sixth and seventh ribs, an inch outward of the inaminillary line, grazing and fracturing the seventh rib. He was treated in the field hospital, and, on May 8th, was transferred to Douglas Hospital, Washington. When admitted, the patient was suflTering from very severe dyspnoea, accomjianied by an incessant, painful, and annoying cough ; respiration was very frequent, forced, and superficial. He stated that he had spat blood after the injury, but not the least tinge of blood was observable in the thick frothy mucous expectoration. An abundant effusion in the left thoracic cavity easily accounted for the dyspnoea. Purgatives, diaphoretics, and stimulants were administered and counter- irritants applied over the left side of the chest, with water dressings to the wound. He died May 10th, 1833. At ihe post-mortem examination, sixteen hours after death, old adhesions were found in the right lung and fresh ones in the left. The effusion of sero-sanguinolent fluid in the left cavity was the immediate cause of death. Paracentesis thoracis wmuld have proved of but little avail, as the diaphragm was perforated and the spleen and left kidney badly bruised and injured. The ball lodged parallel to the transverse process of the fourth lumbar vertebra, near the spine. The case was exceedingly interesting, because the patient had manifested no abdominal symptoms, had no blood in his urine, and voided it freely and without pain in spite of the extensive injury to the left kidney. The case is reported by Acting Assist- ant Surgeon Carlos Carvallo. The missile, with the merest contusion of the rings at one point, was forwarded to the Army Medical Museum by Assistant Surgeon W. Thomson, U. S. A., and is repre- sented in the adjoining wood-cut (Fig. 290). Case 20. — Private J. A. S , Co. C, 145th Pennsylvania Volunteers, aged 19 years, was wounded at Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal ball, which perforated the left scapula just below the spine, and passing forward to the right, splintered the sternal end of the first rib. He was conveyed to the hospital of the 1st division. Second Corps, and, on July 9th, admitted to McKim’s Mansion Hospital, Baltimore, where he died on the same day. At the autopsy the ball was found compressed upon itself in the anterior mediastinum, opposite the first intercostal space. The apex of the left lung was daf lKill'rei^-red*^frora' engorged and the left pleura contained about two quarts of sero-sanguinous fluid. Miliary cysts filled the mediastinum after with pus were seen at the apex of the right lung. The specimen is represented in the adjoining wood-cut grains. SpecMti, Sect. (FiG. 291). The history was contributed by Acting Assistant Surgeon R. H. Sterling. I, A. M. JI. ' ' Case 21. — An unknown soldier, wounded at the battle of Gettysburg, was brought into one of the field hospitals, in an insensible state, with a wound under the malar bone. The ball had taken a down- ward course through the neck into the thoracic cavity, and could not be traced. Pulmonary symptoms arose, and the patient lingered till August 7th, when he died, and, at the autopsy, the missile, a misshapen conoidal, with bony spiculse imbedded in it, was found in the posterior mediastinum, behind the arch of the aorta. The projectile is represented by the wood-cut (Fig. 292). It was contributed to the Museum by the curator. Surgeon J. H. Brinton, U. S. V. Fig. 290. — Ball weighing’ 510 grains slightly contused after passing through the thorax. Spec. 293, Sect. I, A. M. M. To the eight foregoing abstracts of cases of foreign bodies removed from the cavity of the chest after death, should be added some examples of the extraction of the missiles during life. In the five following cases, projectiles were excised from the thoracic parietes ; in one instance, after being encysted for fourteen months : Case 22. — Private Hugh Meehan, Co. A, 63d New York Volunteers, was wounded at Gettysburg, July 2d, 1863, by a ball which entered the right side, between the second and third libs, passed around to the inner border of the scapula and lodged, injuring the edge of the bone to some extent. He was sent from the field hospital of the 1st division. Second Corps, to Patterson Park Hospital, Baltimore, where the ball was extracted on July 31st, 1863, through a counter incision. The wound healed kindly, and Meehan was returned to duty December 11, 1863. The operator. Acting Assistant Surgeon A. T. Pick, presented the missile, represented in the wood-cut (Fig. 293), to the Museum. Fig. 292. — Misshapen conoidal ball lodged hi mediastinum after tr.av- ersing neck. Spec. 143!*, Sect. I, A. M. M. Fig. 293.— Bali studded with par- ticles of bone from scapida. Weiglit, 483 gr.iins. Spec. 1422, Sect. I, A. M. M. Fig. 294. — Conoidal ball laterally flattened, with the apex blunted by im- pact on the scapula. Spec. 3174, Sect. I, A. M. M. Case 23. — Private Joseph Fouracre, Co. B, 1st Delaware Volunteers, was wounded at Antietain, September 17th, 1832, by a ball, which struck the scapula and buried itself in the muscles. Itsjxisition was detected, and it was extracted on September 24th, the date of the patient’s admission to McKim’s Hospital, Baltimore. There were some exfoliations from the scapula, and the wound healed tardily, but ultim.ately cicatrized firmly, and the patient was returned to duty on June 16th, 1863. The projectile, repre- sented by the wood-cut (Fig. 294), was sent to the Museum by the operator. Surgeon Lavington Quick, U. S. V. Case 24. — Assistant Surgeon .1. B. Brinton, U. S. A., contributed the specimen figured in the accom- panying wood-cut (Fig. 295) to the Museum, without further information than that it was cut out from the supra-scapular fossa, where it lay partly impacted in the spine of the scapula, in the c.ase of a soldier of the Army of the Potomac, wounded before Petersburg. This wound healed witliout ill conseiiuences. Fig. 295. — Conoidiil ball roughened by impact with ppino of scapula. Spec. Tcct. I, A. M. M. 590 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, Eiglity-eight abstracts of cases attended by the lodgment of balls or other foreign bodies will be found recorded between page 473 and page 582, or the beginning of this subsection. In over one-tbird of the cases, or tbirty-tliree, the foreign bodies were extracted, either immediately or within twenty days in eleven cases, and at periods ranging from one to twenty-two months in the remainder. Twenty of these thirty-three patients recovered. In seven of the twenty, the missiles had probably not penetrated beyond the thoracic walls ; seven were examples of perforation of the chest and the removal of the ball from lodgment beneath the integument or scapula ; in one, the famous case of Betts (Plate X), the projectile was removed from the mediastinum, and the five remaining cases, of Kuhn, Knowles, Tomlinson, Branson, and Rabell, were believed to be examples of wounds of the lung tissue. Case 25. — Private H. Millineth, Co. E, 9th New York Zouaves, was wounded at Roanoke Island, February 8tl), 1862, by a round musket ball, which entered beneath the anterior convexity of the clavicle and buried itself in the soft tissues. The wound healed without trouble, the ball becoming encysted. Millineth entered Armory Square Hospital, at Washington, a year afterward, with typhoid fever. When convalescent, the ball was detected in the supra scapular fossa, and was excised, April 28th, 1863. The man was discharged, well, May 4th, 1863, on the expiration of his term of service. Surgeon D. W. Bliss, U. S. V., presented the specimen, figured in the wood-cut (Fig. 296). Case 26. — Private Julius Wilt, Co. A, 45th New York Volunteers, aged 22 years, was wounded at Gettysburg, July 1st, 1863, by a conoiflal ball, which entered to the right of the second lumbar vertebra, passed between the skin and cellular tissue, and lodged two inches to the right of the umbilicus. He was taken to the 4th division hospital, where, on the 12th, the missile was cut out. He had also a ragged wound below the right nipple, which appeared to implicate only the soft textures. The treatment consisted of tonics, with simple dressings to the wound. The wound of the back soon cicatrized ; that of the chest continued to dis- charge. The patient became weak and prostrate, but improved under the administration of stimulants and tonics. On November 7th he was transferred to Newton University Hos- pital, Baltimore, at which time the wound of exit had not healed. On March 2d, 1864, Surgeon C. W. Jones, U. S. V., made an incision one and a half inches in length in the side and removed a piece of shell one and three-fourths by one and one-fourth inches, and which weighed one and one-fourth ounces. The presence of this missile had not been sus- pected for a long time. The wound soon afterward healed, and he was transferred to De Camp Hospital, New York Harbor, whence he was returned to duty on September 27th, 1864. The fragment of shell was contributed to the Museum, with the above notes, by the operator, and is represented of the natural size in the adjoining wood-cut (Fig. 297). Of the twenty-six abstracts included in this subsection thirteen relate to the extrac- tion of missiles or foreign bodies during life. One other example may be cited in detail, and the other cases of this description that appear on the returns must be considered numerically. Case 27. — Private Francis Cook, Co. K, 2d Michigan Volunteers, was wounded at Bailey’s Cross Roads, Virginia, Septem- ber 4lh, 1861, by a conoidal ball, which penetrated the lungs. Surgeon William O’Meagher, 37th New York Volunteers, in a report of the case in Am. Med. Times, Vol. IV, p. 6, says : “While on picket duty near the Cross Roads, he received from the enemy’s picket a gunshot wound through the lungs, and when discovered by his comrades, who had hastened to the spot, was found faint from profuse haemorrhage, and lying on the wounded side. By them he was conveyed in a blanket to the main body stationed at the Cross Roads, the distance being about a mile, and on their arrival I saw him immediately. On examination, his clothes behind were found saturated with blood, while several large clots were removed from the immediate vicinity of the wound. As he was extremely prostrated, some stimulants were gradually administered until reaction took place, and, in the meantime, I was searching for the exit of the bullet, which had entered the left side posteriorly, fracturing the tenth rib and making a large irregular wound. On introducing my finger for about two inches for the purpose of exploring and removing foreign substances, I felt the lung tissue, and found the wound itself partially filled with coagula and extending toward the opposite side in a transverse direction ; emphysema appeared to some extent in the vicinity. I did not attempt a further exploiation, especially as the wound, as far as I could discern, appeared free from foreign substances and partially closed. Shredded lint was then applied to the wound, and the patient gently turned over on the wounded side. On searching for the exit of the ball, the only indication of its presence was a patch of emphysema on the opposite side, somewhat higher up than the aperture, but the biill itself could not be felt, so I resolved to wait awhile in order to allow the patient to recover somewhat, hoping that, in the meantime, the respiratory eftbrts, increased by a pretty tight bandage, would force the ball outward and thus render it |>alpable. Accordingly, Fig. 297. — Fragment of sliell removed from the right side, eight months after injury. Sjjcc. 4503, Sect. I, A. JI. M. FIG. 296 Sect. III.] BALLS AND FOREIGN BODIES LODGED. 591 ill aliout four hours, he began to experience severe pain in this part, and on removing the bandage, at the same time directing liim to take a full hreath, -which he did with ease and evident relief, I was exceedingly gratified to find the ball pi’esenting itself in the sixth intercostal space. On cutting down I found it firmly imbedded in tbe costal pleura, and after a little delay, occasioned by a desire not to make a large opening, removed it with a common forceps, and immediately closed the wound with interrupted sutures. The bandage was again applied, and a full anodyne administered, after which he slept well for two hours and felt very much relieved. The missile, contrary to my first anticipations, turned out to be a small triangular-shaped rifie- bullet, irregular and rough at the edges, as if it were so designed to produce greater mischief. Ho continued very comfortable for two days, taking light nourishment and appearing quite cheerful and intelligent, occasionally only being attacked with dyspnma, which, however, was never sufficient to cause any apprehension. Obedient to directions, he lay perfectly still, without talking, except in answer to a.necessary question as to his condition. His bed was a canvas field-stretcher, with poles inserted into the folded canvas, which was also attached to the end pieces by buttons and cords. The iron framework at the ends raised it from the ground sufficiently to afford a safe, easy, and efficacious means of transportation, far supei'ior, in my opinion, to any other thus far presented, and certainly better than field ambulances over rough roads. On this he was conveyed, on the third day, a distance of perhaps ten miles, to the general hospital in Alexandria, where he died on the fifth day. I am indebted to Dr. H. Laurence Sheldon, the surgeon in charge, for the following record of the autopsy : ‘Left side of chest filled with bloody serum; lung compressed, and a space between anterior parietes and surface of lung filled with air. Lymph covered the visceral and parietal pluras, and clots of blood were on the most dependent portion of the cavity. The ball struck the tenth rib, fracturing it three inches from its articulation with vertebrae, passed through the lower lohe of left lung, where there was intense inflammation in its track, with numerous spiculae of bone carried two inches into substance of lung from the fractured rib, thence through body of tenth vertebra, through diaphragm and upper suiface of liver, a distance of two inches; again through diaphragm, and was removed externally between sixth and seventh ribs. There was a patch of pneumonia on the right lower lobe. Half a gallon of serum and blood was taken from both pleural cavities.’ I should have mentioned as rather remarkable, that for three days, though he had considerable dyspnma, and pain referred to in both jilaces, he had neither cough nor expectoration until the fourth day, leading some to suppose that both lungs were not seriously wounded, as I had at first reported, the h.all rather making a circuit outside the lung. But I think it almost impossible that the right lower lobe could escape when the ball passed twice through the diaphragm and upper surface of the liver, being finally removed from the sixtA intercostal space; besides, ‘there was a patch of pneumonia on the right lower lobe, and half a gallon of serum taken from both pleural cavities.’” Besides the forty-seven cases of extractions of balls or foreign bodies from the thoracic walls or cavity that have been cited with some details, were two hundred and sixty-nine, of which only the results can be noted. In the aggregate of three hundred and sixteen operations, a fatal termination ensued in one hundred and eight cases ; in one hundred and nineteen cases, the patients were discharged with various degrees of disability, and eighty-one recovered sufficiently to resume duty, at least temporarily. Forty-one of the recoveries are found among cases in which the projectile was lodged beneath the soft parts, without having injured the contents of the chest. The remaining two hundred and seventy-five were attended either by fr.icture of the ribs, or presumed injury of the contents of the thorax. Of these patients, one hundred and eight are known to have died ; in eight cases, the result is unknown ; and there remain one hundred and fifty-nine examples, or more than one-half, of reported recoveries. As the names of the majority are found on the pension roll, there can be little doubt of the fact of recovery ; but there is every reason to believe that the gravity of the injury was overestimated, and that many cases returned as penetrating wounds of the chest, in reality were wounds of the parietes only. That there were a certain number of recoveries after extraction of balls from the pulmonary parenchyma cannot be denied, but there is a lamentable deficiency in details in the reports of this most important class of injuries.* It must be very rarely that any attempt should be made to discover and extract balls lost and lodged in the tissue of the lung. It is safer to abandon such to the care of nature. LeDran points out a rare exception to this precept, which presents itself, by a happy chance, when from a former pleurisy the wounded lobe is firmly adherent to the walls of the chest. In all other cases, Percy and Desport and Bagieu, who cannot be accused of timidity, advise against attempts *Larrey, D. J., JHe/Ti. de Ckir, Mil., Paris, 1817, T. IV, p. 261; LOIlMlCYER, Die Schusswunden und Hire Jieliandluvg, Gottingen, 1859, p. 124; Rust, J. N., Ucmdbuch der Chirurgie, Berlin, 1856, Band 17, S. 622; BauDICXS, Clinique des plaies des d'armes d fev^ I^aris, 1856, p. 242; Fabrictus Hild^lnus, Ohservat tones CAirwr^icfl?, Cent I, Obs. 46; .Stromkyer, J/aximcn der Krie.gshcHkunst, Hannover, 1861, p. 452; TllOMABSIN M , i?isscr- tation sur Vexlracti&n des corps etrangers des plaies, et specialemeul de ccllcs faites par armes d feu, Strasb., 1788. 592 WOUNDS AND INJUKIES OF THE CHEST. [Cjiap. V, at extraction. M. Demme, on the other hand [Militdr-chirurgische Stiidien, Zweite Abth., S. 138, AViirzhurg, 1864), says: “Entirely unfounded is the fear of a careful examination for the seat of lodgment of the projectile. A systematic search should be made in the direction of the wound, which should be ascertained by the finger or the probe.” Dr. Pirogoff^ [Orundzuge der allgemeinen KriegscMrurgie, Leipzig, 1864, p. 534) severely criticises these precepts of Dr. Demme. Professor Gross {A System of Surgery, 5th ed., Vol. II, p. 446) teaches that “any foreign substance that may be present should be promptly removed, provided it is easily accessible ; for the rule here, as in all other visceral cavities, is to refrain from officious interference.” No one will question the propriety of extracting accessible foreign bodies ; but there will be differences of opinion as to what constitutes officious interference. It is, perhaps, impossible to formulate the general rule more precisely than is done in the language of this learned author ; but the whole question at issue is involved in the interpretation of the rule. I cannot subscribe to the next sentence: “Nothing, in such a condition, can more clearly betray the ignorance of the surgeon than the introduction of the probe into the chest ; a careful exploration of the outer wound is always admissible, especially when suspicion exists that a rib has been fractured, or that a ball has lodged in one of the intercostal spaces.” Dr. Demme, Dr. Cooper, and M. Legouest, are assuredly neither ignorant nor inexperienced, and the case of Dr. Ellis (Lewis, p. 494) alone proves the propriety of undertaking, under some circumstances, very serious operations for the removal of foreign bodies from the lung. The dogmatic teaching of Dupuytren,^ has probably exerted much influence upon modern practice in this connection. He said: “Une blessure de poitrine par armes a feu qui traverse le poumon ne doit jamais etre sondde, e’est la plus grave hdrdsie que I’on puisse commettre en chirurgie, et I’instrument dit sonde de poitrine, que I’on trouve dans les trousses des chirurgiens, devrait bien etre banni, au moins pour cos sortes de Ifisions.” To this, M. Legouest replies, at page 357, of the last edition of his Traite de Chirurgie d'Armee: “Les faits sent en complet disaccord avec ce prdcepte : le seul inconvenient auquel on s’expose en sondant une plaie de poitrine par coup de feu que Ton suppose renfermer un corps dtranger, est de ne pas trouver ce que Ton cherche. En effet, ou bien le poumon fibre d’adhdrences s’est rdtraetd vers sa racine et dchappe I’instrument explo- rateur qui parcourt sans obstacle la cavitd pleurale; ou bien le poumon est adherent k la plevre costale et sa blessure reste en rapport avec la plaie extfirieure. Dans ce dernier cas, une sonde de poitrine ou une sonde de gros calibre de gomme dlastique pent etre introduite dans le trajet escharififi de la plaie du poumon, sans courir le risque de causer une irritation plus vive que la presence de la balle, d’esquilles, de vetements ou d’autres corps entrainds par le projectile. Si Ton dtait assez heureux pour rencontrer le corps dtranger dans le poumon, il faudrait, comme le conseille Ledran, dilater suffisamment la plaie extdrieur pour aller le saisir avec des pinces et I’extraire sans obstacle.” The general opinion among military surgeons in the war of the Rebellion appeared to be that it was always well to complete the diagnosis, for nothing can be better than the entire truth ; ^He also adverts {1. c. S. 549) to the remarkable operation by Dr. COOPER, of San Francisco: “Of desperate operations successfully performed for injuries of the chest, few arc worthy of imitation. Nearly all concern the removal of forei^ bodies from the cavity of the c-hest. A few of these adventurous operations resulted successfully. One of the most desperate cemes to us again from America. It is a case related by Dr. E. S. COOPER (of San Francisco), in 1857.” See COOPER, E. S., Ilcport of an operation for Removing a foreign hody from beneath the Ecart. (rublishcd by the San F rancisco IMedico-Chirurgical Association as an additional paper to its Transactions for the year 1857.) Dr. W. F. Atlee (.\iu. J.tuir. (ff Jlcd. Sci., N. S., Vol. XXXV., p. 229) remarks of this operation that “it is extraordinary cvcn.for California, that land of enormities of every description.” ^ Dl’PUYTREN, oraUs de clinique chirurgicale, T. VI, p. 382. Sect. III.] BALLS AND FOREIGN BODIES LODGED. 693 but when tlie means of arriving at it might do more harm than the knowledge of it could do good, it was the part of wisdom to know when to be willing to remain in doubt. The authors of the Confederate Manual^ declare that “if the presence of a ball within the cavity be ascertained, efforts should be made for its removal. But any attempt to determine where the ball has lodged should be made very cautiously, as more harm may result from the interference than from the lodgment of the foreign body.” Examples have been cited (p. 481, et seq.) of the fatal consequences of the rash and unwarrantable explorations that the authors that have been quoted and others reprehend ; but surely there is a wide interval between such meddling and the judicious use of the probe and forceps in cases in which there are just grounds for suspecting the presence of a foreign body, and the sagacious practitioner will neither discard the probe absolutely nor use it habitually. It is almost needless to repeat that all good surgeons agree that the finger is the best probe whenever available. The surgeon will remember that a ball striking the chest may lodge in the soft parts near the point of impact,^ or be deflected to distant parts, ^ or it may be impacted in a rib,^ or wedged in an intercostal space,^ or lodged in the sternunE or spine,'’' or against the clavicle® or scapula;® or it may fracture the rib and push the costal pleura before it and not penetrate the cavity;^® or, penetrating the cavity, it may lodge either in the walls or in the contained viscera or in the cavity, or pass out of the cavity and make a wound of exit, or else lodge under the skin, scapula, or soft parts near its emergence from the thorax. Perhaps it would be best to restrict the term perforating gunshot wounds of the chest to the cases comprehended in the two latter subdivisions. The ball may perforate the chest through intercostal spaces without fracture, or there may be fracture at the point of impact and not at the point of egress, or the reverse; or the ball may traverse the mediastina or both sides of the thorax, or enter the chest by pushing aside the cartilages ; or, lastly, it may penetrate through the neck or diaphragm, as has often occurred since the use of arms of long range has frequently justified the adoption of the prone position under fire. The ball may carry with it various extraneous matters, or portions of the bony case it has encountered in entering. Examples of nearly all of these various forms of injury have been enumerated and others will be found in Table XXII. I avail of the remaining space to intro- duce illustrations of foiu" other specimens, the histories of which are briefly as follows: Fig. 298 represents a missile which struck Corporal S. M. Elder, Co. K, 10th Pennsyl- vania Reserves, at Fredericksburg, Decem- ber 13th, 1862, in the third right intercostal space, and was extracted, January 19th, 1863, by Surgeon O. A. Judson, U. S. V., near the lower angle of the scapula. Elder recovered and was pensioned. Fig. 299 rep- resents a post-mortem specimen found in the body of Lieut. H. II. W , Co. D, 0th Maine, wounded at Rappahannock Station, November 7th, 1863, the ball fracturing the stcnium and first rib and entering the apex of the lung. The case terminated fatally in six days. Fig. 300 represents a heavy ball extracted December 21st, 1862, from near the spine of the left scapula, by Assistant Surgeon W. A. Conover, U. S. V., having entered December 13th, 1862, in the third left intercostal space anteriorly in the case of Private J. Porret, Co. B, 105th Pennsyl- vania, wounded at Fredericksburg, who sub- sequently recovered and was discharged. Fig. 298. — A conoidal ball of unusual slender- ness. The two lower thirds arc compressed on one side and bear markings as if of the texture of coarse cloth. Spec. 4657, Sect. I, A. M. M. Fig. 299. — An elongated rifle ball somewhat blunted and flattened upon one side in which small fragments of bone are imbedded, with one and a half inches of brass wire hooked in the apex. — Spec. 2651, Sect. I, A. M. M. Fig. 300. — Ball weighing 840 grains, with the body flat- tened obliquely and two short lateral grooves near the apex. Spec. 4399, Sect. 1, A. M. M. Fig. 301. — Ball split in traversing tlie chest. Weight 684 grains. Spec. 573, Sect. I, A. M. M. Fig. 301 represents a prqiectiie that passed through the chest of a soldier at Gettysburg, and then lodged deeply in the soft parts of the man behind him, whence it was extracted by Acting Assistant Surgeon B. B. Miles. •A Manual of Military Surgery, prepared for the use of the Confederate .States Army, by order of the .Surgeon General, Richmond, 1863, p. 60. ^See page 473. ^Besides the examples given, see IIExnen (h c., p. 392), Gutiiuie (I. c., p. 464). ‘•Page .569. ®Page568. “Page 474. ’Chapter IV, p. 460. “Page 475. “Page 476. '“See a remarkable case related by D. J. Laiirey (Jour. G6n. do Mfid., T., LXXII). 594 WOUNDS AND INJUEIES OE THE CHEST. [Chap. V, • ?> 6 O ?:> O r*s ?: CO CO o g r'^ M <1 (-5 ’ ^ Pq I g § §6 00 I f>o .§ g g •i ) O K a 9 fH H < < Iz; ^ ’ .Q B « r} •*rr « a> . .b-o -a « 'd P< o o O jJ ^ >» i O 0^0000 ct c^i a c< (?< a a bD be bo Q Q CO CO 00 00 bo s ho £ bo bo s <3 Q P « P S ^ CJ «£3 $ 5 ‘5 rt P ^ P -S S " -2 d o » ^ .52 S cc 53 XI J o ^ X z Z S 2 S P o *-*< M 02 K S P P P Ph • • • 53 : j : ^ .5 1 ’ p *o • • • 0) ^ o £ § *- • . ■ ' £3 •2- £ 0) " S U P P P n3 I? s Cl Cl Cl Cl p p ^ 5 -s bo p CC Cl CC CC CO Cl CC Cl CCtOCOCOtOCCOCD^ OOCOCOOOCOCOOOCOCO be 3 <3 ?OCOCOCDCOtO^O?0 QOOOQOOOCOOOCOCO - S 2 p ij iJ o 03 -n rt rs 2 ^ « 2 00U00KW020 H p p? 02 02 Sect. III.] SPECIMENS OF FOREIGN BODIES EXTRACTED 595 a ^ s s c w P.'O toS a c3 s ^ to E to E « P P5 M PJ 3 .3 pjOaPCjppjQ P P P P P .O .2 H p O W O O P .2 to S:2 2 § •'o 3 Cl » 12; o h5 o <: n pH pH p < TC 00 00 CD CO CJ CD CJ CO CO o to CO o o i:;: QO 00 00 CO CD c» fcx) 'C S P- < <: Cl ^ CO CO CO CO CO Cl CC CO to O 'O to CD 00 CO 00 CD CD >5 0 0 <3 70 Cl CO CO CO OO CD 00 CO to CO to Cl CO CO CO >5 < < 00 00 CD OO *5 3 5 tocotocococotoco OOOOCOOOCOOOGDOO ti) ^ Q < ^ > ^ o S >5 z. .3 .3 C fcfi IsD . .3 s !2 S 2 2 bo lo 2 C3 iJ bo .5 fl "B « •- « rs rH n p p Q C5 O a p p 1 § -5. I 2 ^ p 3 o o S < P --r-H?ooocoi*ciao-^r-co o lO -H O CO CO TO Cl Cl 00 Cl •(}• lO O O O LO »o lO rr to co-^ioor-'CQO o — < Cl cococococortco -r ■«»* ^ C3> Ci Cl O »-0 to I- CO O O ^'9*’^'^TrTj»»c5K0 S o to to Dut}-. t Died. { Discharged. 596 WOUNDS AND INJURIES OF THE CHEST. [CiiAr. V, Several examples of balls or other foreign bodies remaining within the cavity of the chest for seven or eight years, have been related. Sufficient time has not elapsed since the war to afford jrarallel instances to those recorded by Larrey and Hennen and Guthrie, and those readers whose appetite for the marvellous is not appeased by the two following abstracts must be referred to the works of those authors and of others cited in the foot-note Case. — Henry Miltenberger, Co. K, 12th Ohio Cavalry, aged 20 years, was injured, June 9th, 1864, at Mount Sterling, Kentucky. In a report in the Medical and Surgical Eeporter, Vol. XVI, ji. 404, Dr. A. Geiger of Dayton, Ohio, says: “He was struck, at Saltville, V.u., April 7th, 1834, by a minie ball in the left side; the ball entered at the lower margin of the seventh rib on a line parallel with the axilla. He bled severely at the time, but refused to be carried to the hospital, and remained with his comrades in camp, and after five days started on horseback with General Stoneman’s brigade into Georgia, South Carolina, etc., and continued with his regiment until the close of the war. He states that after the healing of the wound externally he did not experience much inconvenience, except occasional shortness of breath and inability to perform active exercise, such as fast walking, running, etc. After being discharged from the army, he returned home and engaged in work at his trade, that of a carpenter, and continued to enjoy tolerable good health, until, some time in September, 1866, he contracted, by exposure, a severe cold, since which time he has had some cough and frequent expectoration of blood. Also, at times, complete aphonia, with sense of sulibcation. One of these attacks was so severe as to produce spasms and insensibility, which continued for several hours. Oftentimes, during a severe fit of coughing, accompanied sometimes by vomiting, he would feel the presence of a hard body in the wind pii)e, which he could almost at the time cough up. On the 26th day of March, 1867, after having been at work during the forenoon, he felt so unwell at noon that he returned home, and, in a short time afterward, was taken with a severe fit of coughing and soon expectorated a minie ball, weighing three-fourths of an ounce and the one’ that, nearly thfee years previous, had entered the left side. The ball was covered entire with a tough mucous coat, and the small cavity at the base was filled with pus. Considerable hminorrhage followed the expectoration of the ball, but the relief he experienced was so great that he rejoiced to be rid of his unpleasant companion that for so long a time had been the occasion of so much discomfort. He still continues to expectorate small quantities of blood and bloody mucus, but he considers himself so much better that he is engaged in working at his trade, and he is of the opinion now that all will soon be right with him. It might be idle to speculate as to where this ball has been during this long period, and the course it may have traveled to find its way into the bronchi, and then to the trachea, or it may at first have lodged in the bronchia; but it is a remarkable instance of the ‘vis medicatrix naturw,’ in an otherwise healthy young man, and of the surprising efforts nature will sometimes make to rid herself of an incumbrance that would interfere with the normal action of her functions.” In his declaration for pension Miltenberger states that a ball entered his right lung and lodged, and was coughed up in February, 1866. Said wound has caused disease of the lung with constant pain, and at night he cannot sleep on account of almost constant coughing. In a second declaration he states that he was treated in the hospital at Lexington, Kentucky, for two months; was home on furlough for thirty days; was afterwards treated in hospital at Camp Dennison, Ohio, where he remained until March, 1865, when he was returned to his regiment for light duty. Pension Examiner C. McDermont, Surgeon Nation,al Military Asylum, Dayton, Ohio, under date of January 26th, 1871, states that the applicant came under his charge in the winter of 1866-7, at Dayton. 'When called to see him he was sufl'ering from intense dyspnoea and had to be constantly prop])ed up in bed. The symptoms were those of pneumonia. During the treatment, he expectorated a ball in connection with bloody mucus and pus, and soon afterward recovered so that in the following summer he was engaged working at his trade. He occasionally called to see him about his lung, which he stated was, at times, so painful as to prevent his working. He was not present when Miltenberger threw up the ball, but saw him a few hours afterward, and all the circumstances of the case, especially the marked relief which the discharge of the ball brought, after about four days of intense sufl'ering from dyspnoea, compelled him to believe that the attack was due to the presence of the ball in the lung. The application for pension is still pending. The official reports in this case are briefly as follows : That the applic.ant was injured at Mount Sterling, Kentucky, June 9th, 1864, “by the falling of a horse,” signed by Surgeon George W. Brooks, 12th Ohio Cavalry; that he was admitted to general hospital at Lexington, Kentucky, June 12th, 1864, with “contusion of muscles of the back, — kick of a horse, received at Blount Sterling, — returned to duty June 23d, 1864,” signed by Acting Assistant Surgeon Robert Peter; “admitted to regimental hospital, July 19th, 1864, with diarrhoea; sent to general hospital, July 24th, 1864,” signed by Surgeon G. 'W. Brooks; admitted to Lexington general hospital with “inguinal hernia in right iliac region, by a kick from a horse; furloughed September 18th, readmitted October 16th, transferred October 17th, reported at Camp Dennison, Ohio, October 23th, 1864,” signed by Acting Assistant Surgeon Robert Peter; “admitted to Camp Dennison, October 26th, 1864, with inguinal hernia; furloughed for twenty days, February 22d, 1835; readmitted March 18th, * Delius, of Erlangen {Amxnitates Mediae circa casus viedico-practicos haud vulgares, Lipsia!. 1747, Vol. V, p. If)!), speaks of a soldier coughing up a ball long after the reception of the injury. ItEViiiLLfi-PAlllsE. Deux observations sur des corps etrangers qui ont sejourvi dans la poitrinc d, la suite des plates penetrantes de cette partie; in Arch. Gin. de Med., Mai, 1825, T. VlII, p. 539, relates that a Captain of the 115th of the line received in October, 1813, on the bank of the Bidassoa, a gunshot wound of the right side, the ball traversing the chest, entering through the shoulder-blade and emerging at the cartilage of the fourth rib near the sternum. He expectorated, twelve days afterwards, a piece of blue cloth and a small sequestntm. A year subsequently, he e.vpectorated a larger sequestrum, and then recovered his health completely and resumed his militarj' duties. lie aftenvards married and begot two children. In 1825, he enjoyed good health. Baron Percy (/. c. p. 125) tells of his friend M. the Marquis of Bavilly, who enjoyed good health, though shot in the chest ten years before, and having expectorated many patches, and even pieces of tow used as wadding. Professor Gross (Practical Treatise on Foreign Bodies in the Airqiassages, 1854, p. 58) recalls the instance recorded by Farricius IIildaxus (op. om., p. 41, ie82, already cited in note to p. 591), that of TULI’IUS (Ohservat. Medic. Lib. II, obs. 15, Amsterdam, 10.52), and that of Pigray (Epitome des Priceptes de midecine et chirurgie, llouen, 1042), of necrosed fragments of bone and pieces of tents coughed up three, four, and six months after injury. In his Sgstem, 5th cd., Vol. II, p. 400, Professor GROSS cites other cases, and among tlicm, two ‘‘of the spontaneous expulsion of bullets in the act of coughing.” Dr. F. II. Hamilton (Prin. and J^ract. of Surg., 1872, p. 11‘2), misleads his readers by referring fjr the above ease to the New York Medical Kccord, Jan. 15, 1807, which contains no allusion to it. Sect. III.] BALLS AND FOREIGN BODIES LODGED. 597 iiiid rotuniod to duty March 21st, 18(3.",” signed liy Surgeon C. JIcDcnnont, IT. S. V. Tliis is all the ('vldcncc* iircsented hy Iho otlicial tiles of the Sui'geon General's Oilice; hut, in his second aiiplication, tiled at the Ih'iision Jtureau, Miltenbergiu- adds tin' following testimony : “Wallace K. Hughes, jM. D., Berlin Centre, Mahoning County, Ohio, under oath, declares that he was the surgeon of the 12th Ohio Cavahy, and that he treated Miltenberger while in the service aforesaid. He attended Miltenberger during the time between June 9th, 18G4, and June 11th, 18G4, and March, 1865, to November, 1865. At the battle of Mount Sterling, Kentucky, June 9th, 1864, at about nine o’clock A. JI., Miltenberger was wounded by a minic ball in the left lung, the ball lodging. He was sent to hospitals and did not again return until in IMarch, 1865, and I treated him from March, 1865, to muster-out of regiment, November 14th, 1865, for said wound. Ball I'emained in his lung up to date of his di.seharge and had produced phthisis pulmonalis.” The official arm}’ register of the Volunteer force of the United States Army, jtublished by the Adjutant General, Washington, August 31st, 1865, states, Bart V, p. 19, that Surgeon G. W. Brooks, 12th Ohio Cavalry, resigned August 7th, 1865, and that Assistant Surgeon Wallace K. Hughes, 12th Ohio Volunteers, was promoted Surgeon, September 2t/th, 1865. The affidavit of Dr. Hughes is not in accord with the certificates of Drs. Brooks, Peters, and McDerniont, or the report of Dr. Geiger. The apj)licant informed Dr. Geiger that ho was wounded at Saltville, Virginia, April 7th, 1864, and Dr. Hughes states that this particular wound was received at Mount Sterling, .lune 9th, 1864. The applicant alleges that he expectorated the ball in February, 1866; he told Dr. Geiger that it was ejected on March 26th, 1867. Erastus Moderwell, late Major 12th Ohio Cavalry, testifies to knowing Milteidierger intimately, and to the wound of the lung as above stated, and that the soldier was under his immediate command. Major Moderwell was, himself, pensioned for a very curious injury. He was rcporteroduction. Drs. Andrews and Higgins (whose ]).atient Mr. D. was), were perfectly assured that the bursting of the bubble on the surface of the jms was the rationale of the sound. Fragments of watch and bone, together with shot and other extraneous matters, continued for some time to be * The original histories of the cases of transfixion of tlie cliest hy a gig-shaft, witli recovery of thirteen years' iluralion, iiiul hy an iron-pointed try -sail yard, in the person of a sailor, who suivived many years, are presened, witli the instruments of penetration, in the Hunterian JInsemn (sec Hr. EAltLE's account. Am. Jrmr. Med. Sci., N. .S., Vol. It. p. 117). Jlr. .SOUTH gives a good account of them in ids Xiiles to Clielius. Hr. IIoi'STOX, of Wheeling (Am. Jour. Med. Sci. X. S., Vol. I.X, p. 3-12), records a case in wliich a piece of coarse linen, two inches and a half in length hy two in width when unrolled, the patch of a ball that had pertbratod the lower lobe of the right lung twenty-five years previously, was found, after death, in a cavity opposite the fifth intercostal space. The cavity was lined with a tough membrane, and communicated with several hronehial tubes. The speeiincn was presented to the Wistar Museum. .Surgeon J. .1. li. WluoilT's account of the case of (lencral .Shields, whose right chest was jierforated hy a canister shot at Cerro Gordo, April 18, 1847, may serve the junior medical officers us a model clinical history. It is iirinted in Hr. E. II. llA.MlLTOX's J’raclical Treatise on Military Surgery, New York, ISfd, p. 157. 598 WOUNDS AND INJURIES OF THE CHEST. [ClIAP. V, ejected by expectoration with sputa. Mr. D. possesses now, every part of the watch except tlie liands, a considerable portion of the small worls having been expectorated. Tbe openings into the lung were of sufficient size to allow a current of air to escape, and, if directed against the dame of a candle to extinguish it. Mr. D.’s liealth continues feeble, but is as robust as it had been during the past five years.” The surgeon will not forget that it is possible that the ball supposed to have lodged in the chest may have pouclied the clothing and been withdrawn when the patient was undressed,* and on the other hand that two opposite wounds do not necessarily imply perforation by a hall, hut may indicate the lodgment of two balls. Of halls passing from the chest into the abdomen, and voided at stool, some remarkable examples have been adduced. Of those encysted in the lung substance, and the local alterations to which they give rise, and of those producing abscesses and thoracic fistulm, I shall have something to add farther on. They are less dangerous than those that lie free in the cavity, rolling on the diaphragm. Such, Baudens would have us search for with a sound, armed with a sharp stylet, to be thrust through the intercostal space from within outward, as a guide for incision, when the seat of the foreign body is detected. I concur with M. Legouest that it is better to make the incision without this dangerous auxiliary. I think that the experience I have endeavored to sum up fully warrants the employment, with due dis- cretion, of persevering efforts to detect and extract foreign bodies from the chest in the very limited number of cases in which there is a probability that the search can be success- fully prosecuted without jeopardy to life, — which, perhaps, is but a restatement of the pi'oposition in different terms. I have ventured to include with the operations the all- important subject of the treatment of wounded arteries in the clavicular region, an innovation which I trust my colleagues will approve.j* The section may be concluded with the following summary of operations on the chest; Table XXIII. Numerical Statement of Four Hundred and Ninety-four Oi:)eration8 in Cases of Injuries or Diseases of the Chest. OPERATION. Cases. Died. Discharged. Duty. Result Unknown. ‘25 20 5 Ligation of the Internal Mammary ‘2 2 Ligation of tlie Suprasca])ular 1 1 8 6 2 Ligation of the Axillary 13 13 Ligation of Branches of the Axillary 2 1 1 Excision tif portions of tlie Clavicle 11 7 4 4 1 2 1 Excisions of portions of the Ribs 4 1 3 84 24 42 18 24 15 2 Extraction of Balls and other Foreign Bodie.s 316 108 119 81 8 Aggregate 494 198 185 103 8 * Else he may be subjected to the mortification experienced by the surgeon mentioned by Dr. FRASElt, into whose charge fell an officer who bore his rough pokings patiently for a considerable time, and then inquired, “ What are you doing? " and met the reply, “ Searching for the ball, with the ejaculation. “ I wish you had said so earlier, because you will find it in my waistcoat pocket.” It is remarkable that identically the same incident occurred to Bordenave in the case of the Marquis de Besons (see Bagif.u, Examtn de Plusieurs Parties de la Chirurgie, Baris, 175fi, p. 25). t Since the achievements of Dr. Billroth and others in tbe recent Franco-German war, I am led to regard the management of wounds liable to involve the great vessels at the upper part of the chest as perhaps the most important field of study for those who occupy themselves with questions of jvhat the French term la haute chirurgie. Sect. III. ] KECAPITULATION AND GENERAL OBSERVATIONS. 599 Section IV. , WOUNDS AND INJURIES OF THE CHEST. Mortality, Complications, Diagnosis, Treatment. In the preceding sections of this Chapter some particulars have been presented of five hundred cases of wounds of the chest, and more general reference has been made to an aggregate of over twenty thousand such injuries, distributed as follows ; Table XXIV. Numerical Statement of Twenty Thousand Six TIundred and Seven Cases of Wounds and Injuries of the Chest reported during the War. ClIARACTEU OF WOUND. Cases. Died. Discharged. Duty. Undeter- mined. Ratio of Mortality. 9 1 4 4 11 1 Bayonet Wounds 29 9 6 12 2 33.3 27 8 5 14 29 6 6 4 1 1 66. 6 225 5 15 205 2.2 Simple and Compound Fractures of Ribs, not gunshot 47 4 9 25 9 10. 5 Gunshot Flesh Wounds 11, 549 113 1, 790 8,988 658 1.0 Gunshot Penetrating Wounds 8,715 5,260 1,939 1, 204 312 62.5 Totals 20, 607 5,404 3,769 10, 453 981 27.5 It might be supposed that, with so large a body of facts determined with reasonable accurticy, and the total number of wounded being known ajiproximatively, it would be easy to compute the relative frequency of wounds of the chest and of those received in other regions of the body. But it must be considered, that the complete statistics of the battle- field are never ascertained. In engagements of magnitude, the number of killed in action is rarely determined with precision, for both victors and vanquished report many “missing,* whose fate is unknown. The exact information we possess of the character of the wounds of those known to have been killed, is comparatively small. Doubtless, a large proportion, perhaps the largest proportion, of speedily mortal wounds, are attended by lesions of the lungs or great vessels. The men fall and die, more or less rapidly, from syncope or asphyxia ; but all precise knowledge of the nature of their injuries is lost. If it is attempted to frame estimates from the number of wounded coming under treatment only, other difficulties arise. Several wounds in the same individual are vommon, and the same ball traverses frequently several organs or regions. Therefore, approximations only are attainable. The figures in Table XXIV are taken from lists including the names and descriptions of injuries of two hundred and fifty-three thousand one hundred and forty-two (253,142) wounded men.'“' Hence, it may be rouglily stated that the proportion of wounds of the chest to the wlrole numlier received in field or siege operations was about one in twelve. *When the lists have been exhaustively compared and verified, it is estimated that this aggregate will bp augmented to about two hundred anil seventy thousand (i270,000) eaises of wounded men reported by name. 600 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V, For tlie last year of the War, nearly complete numerical returns of all the wounded in action, in the Union Army, exclusive of those killed in battle, are available. In the following statement (Table XXV) is set forth the relative proportion of wounds of the thoracic walls and cavity to the total number of wounds, excluding only, a few reports in which the flesh and penetrating wounds were not distinguished. The Confederate wounded that came under our care, are not included in this return. It will be seen that the mean proportion of all chest wounds (7,173) to the aggregate of wounds of all regions (105,540) is a little less than one in fifteen. The highest ratio is for the open field fighting of the Army of the Shenandoah (9.38 per cent., or about one in ten) ; the lowest for the force besieging Mobile by regular approaches (3.83 per cent., or one in twenty-six nearly). The ratio is explained by the unusual predominance of the proportion of head injuries among these entrenched troops. Table XXV. Partial Numerical Statement of Gunshot Wounds of the Chest in the Field or Primary Hospitals in various Carupaigns during the last year of the Rebellion, 1864-65. Battles, Action, or Series of Engagements. WOtINDS OF Thoracic Farietes. Penetrating ■Wounds of Chest. Missile. Total 'Wounded. | Percentage of | Chest 'Wounds, i Names or dates. Cases. Deaths. Cases. Deaths. Large projec- tiles, casnoD shot. »IieU, and bomb frag- ments, grape, and canister. Small proiec- tiles, muvkct, carbine, riilc, pistol balls, and small mis- siles ftom shrapnel and canister. *Army of the Potomac from May 4th to August 31st, 1864 1,013 0 1, 025 366 220 2, 392 38, 944 6. 77 Armies of the Cumherland, Tennessee, and Ohio during the Campaign to Atlanta from May 4th to September 8th, 18P4. . 818 28 908 408 100 1,618 23, 308 7.66 Armies of the Cumberland, Tennessee, and Ohio, and Cavalry, General Hood’s invasion cf Tennessee, from October 25th to December 31st, 1864 132 2 86 16 19 195 3,010 0.03 General Sherman’s Campaign in 1865 through the Carolinas. .. 56 1 52 22 1 105 1, 553 7.04 Armies cf the James and Ohio, etc., from Fort Fisher to Golds- boro’, N. C., 1865 43 1 53 13 21 70 1,075 8. 93 Army of the West Mississippi during the siege of IMobile, from 43 38 3 14 61 2 111 3 83 Anny cf the James during General Grant’s Campaign against Petersburg from May 4th, 1864, to April Cth, 1865 475 5 400 107 86 808 16, 120 5.80 Engagements in the Shenandoah Valley, May 4th to August 2Cth, 18C4 126 3 80 22 16 189 2, 196 9.38 Campaign in the Shenandoah Valley, Aug. 21st to Dec. 3Cth, 1864. 303 193 38 38 451 7,542 6.57 *Army cf the Potomac from Sept. 1st, 1864, to Apiil 9th, 1665. . . .301 8 248 75 30 530 9,101 6.69 Aggregate 3, 970 54 3,203 1,070 545 6,419 105, 540 6.79 M. Scrive, from extensive data,'}* derived from the French returns from the pitched battles in the Crimea and from the trenches before Sevastopol, estimates the relative frecj^uency of chest wounds in the total of wounded as one in twelve in siege operations, and one in twenty in open field fighting. * Incomplete. tSciiiVli, Relation HHico-ChirurQicalc de la Campagne d' Orient^ P.^iris, J857, p. 443. The author gives the relative frequency of wounds, according to their spat in the principal divisions of the body as, in sieges : For the head, 1 in 3.4 ; the neck, 1 in 4G ; for the chest, 1 in 12 ; for the abdomen 1 in 15; the upper extremities, 1 in G.2; the lop^er extremities, 1 in 4.3. In open field actions: For the head, 1 in 10; the neck, 1 in 112; the phpst, 1 in 20 ; the abdomen, 1 in 40 ; the upper extremities, 1 in 4.3 ; the lower extremities, 1 in 3.5. Sect. IV.] RELATIVE FREQUENCY OF CHEST WOUNDS. 601 In the British Army in the Crimea, the proportion of chest wounds to the aggregate in which the seat of injury was determined was as one in sixteen.^ M. Chenu gives the relative frequency of chest wounds to the total number of wounded in the French Army in the Crimea” as one in twelve and one-sixth, and in the Italian war of 1859,^ as one in thirteen and eight-tenths. Dr. StromeyeF gives the proportion of chest wounds in thirteen hundred and ninety- four hospital cases of wounded under his care at Langensalza, as one in twelve and six-tenths. After the battle of Idstedt,® in the Danish AAar of 1855, he treated twelve hundred and ten cases, and the iiroportion of chest wounds was nearly one in twelve. Demme* *’ tabulated the wounds of eight thousand five hundred Austrians, and of eight thousand five hundred and ninety-five French and Piedmontese, in the hospitals at Pavia and Brescia and Milan, in 1859, and made the proportion of chest wounds to the aggregate one in twelve and a half for the former, about one in fourteen in the latter. Professor H. Maas,’’’ of Breslau, had under his charge in the Silesian campaign of the Six-Weehs War, two hundred and twelve wounded, of whom eighteen, or one in twelve, had chest wounds. Professor H. Fischer® treated, at the siege of Metz, eight hundred and seventy-five wounded, the proportion of chest wounds being about one in twelve. Dr. Bernhard Beck** reports, after the action at Tauberbischofsheim, fifty-seven wounded, with a proportion of chest wounds of about one in ten. The same distinguished surgeon^® reports the cases of four thousand three hundred and forty-four wounded in the engagements about Strasburg, in 1870, of which one-twelfth were chest wounds. Dr. SerrieP^ long since collected, from observations by H. Larrey, Jobert, Dupuytren, and Baudens, the statistics of. seven hundred and eighty-four cases of gunshot wounds, of which fifty-three, or nearly one in fifteen, were in the chest. But it is needless to recapit- ulate statistics so often copied. After Sedan, six hundred and ten wounded were treated at the Anglo-American ambulance at the chateau of Asfeld, on the battle-field, about one-twelfth having received chest wounds. Mr. MacCormac^^ has carefully classified these injuries. ^ The total number of Dritish officers wounded during the Crimean War was 579, of which number 54, or about 1 in 10, received chest wounds. During the period from the debarkment till the end of March, 1855, there were reported among non-commissioned officers and men 4,434 wounded ; but in 1,815 of these the seat of injury was undetermined. Of the remaining 2,619 cases of wounds, 153 were of the chest. During the second period, from April 1, 1855, to the end of the War, the wounded non-commissioned officers and men reported numbered 7,153, from which 72 cases remaining under treatment and enumerated in the first category should be deducted, leaving 7,C81 determined cases, of which 420 were chest wounds. Hence, 579 4- 2,619 + 7,081 = 10,279, or the aggregate of determined cases of wounds, and 54 -p 153 -fi 420 = 627, the total of chest wounds, and 10,279 627 = 16.3, the proportion of chest wounds to the aggregate. ^ M. Chknu {op. cii., pp. 627, 636) gives the total killed and wounded of the French Army in the Crimea as 50,826. Deducting 10,240 killed, there remain 40,586 wounded. In 34,306, the seat of injury was reported, and 2,818 were returned as wounds of the chest, or 1 in 12 1-6. * In the Italian War of 1859, M. Chenu {op. ci7., T. II, pp. 474, 851) states the French losses from the enemy's fire at 19,590, including 2,536 killed outright. Of the remaining 17,054 wounded, 1,052 received wounds of the chest, or J in 16.2. ^ Stromeyeu, L. Erfahrungen iiber Schusswunden im Jahre 1866, Hannover, 1867, S. 18. Of 1,394 cases of gunshot wounds, 110, or 1 in 12.6, were of the chest. *DERSEL 15 E. Maximen der Kriegsheillcunst, Hannover, 1855, S. 585. “ Of 1,210 wounded near idstedt, 97 had injuries of the thorax,” or 1 in 12.4 ® Demme. Miliidr-Chirurgische Studien^ Wurzburg, 1861, Erste Abth., S. 19. Of 8,500 wounded Austrians, C80 were struck in the chest, or 1 in 12.5; of 8,595 French and Sardinian wounded, 595 Iiad chest wounds, or 1 in 14.4. ^Maas, H. Kriegschirurgische Eeitrdge, Breslau, 1870, S. 72. At the hospital at Kachod, in central Silesia, Professor Maas treated 212 wounded Prussians, among whom, 18, or 1 in 11.7, had been struck in the chest. ® Fischer, H. Kriegschirurgische Erfahruvgen, Erlangen, 1872, Theil I., S. 28. At the hospitals of Forbach, Styringen, Keuenkirchen, and Ottweiler, under Professor Fischer's charge, of a total of S75 cases of wounds, 76, or 1 in 11.5, were of the chest. Beck, B. Kriegschirurgische Erfahrungen^ Freiburg i. B. 1867, p. 26. Of 57 cases, the chest was injured in 6, or l.in 9.5. *®Derseliie. Chirurgie der SchussverUtzungen, Freiburg i. B., 1772, Erste llalftc, S. 160. Dr. Beck was genenilarzt of the fourteenth German corps, the Bavarian army corps of General Werder, in the late Franco-German war. He reports an aggregate of 4,344 wounded, of which 361 had chest wounds, or 1 in 12.03. ** Serrier. Traiti de la Nature, des Complications, et du Traitement des Plaies d'Armes d Feu, Paris, 1844, p. 30. •^MacCORMAc, W. Notes and Recollections of an Ambulance Surgeon, being an Account of Work done under the Red Cross during the Cam- paign of 1870, London, 1871, p. 127. M. Duplessis, chief physician of the military liospitals at Sedan, placed, on August 31, 1870, the day before tho great battle, the barracks at Asfeld, a hospital of 384 beds, in charge of the 16 surgeons of the Anglo-American Ambulance. Mr. MacCorniac reports that they received 610 wounded, of whom 54 had received wounds of the chest, or 1 in 11.29. 70 602 AVOUNDS AKD lAMUIlIKS OF TIIP: CHEST. [CliAr. V, Tims a comparison of the returns ol' the War of the Kehellion Avith those from the Crimea,* the Danisii, Italian, Bohemian, arul Franco-German aath's, i)resents a remarkable uniformity in the comparatiA’e frecjuency of Avouiids according to their seat. Of information regarding the seat of injury in those killed in battle, Ave possess but little, and that little is, ibr the most part, in the shape of general observations, insuscep- tible of reduction to numerical estimates. Dr. Fraser remarks that “if it Avere not for the financial objection, a special staff of medical men might Avell be employed during circumstances similar to that in which the army Avas placed before Sebastopol, or in any standing camp before an enemy, to ascertain the kinds of Avounds Avhich kill on the field.” The humane objection comes in also ; for, in large conflicts, the medical staff is invariably insufficient numerically, and all auxiliaries are brought into requisition. Yet, in our lines before Petersburg, a zealous and indefatigable surgeon, to Avhose contributions to field surgery I have such frequent occasion to advert, found time to examine nearly all of the dead bodies left on the field after a brisk and deadly assault. This obserAmtion of Surgeon * 1 take the liberty of quoting entire Dr. Fraser s tables of the chest wounds in the British anny in the Crimea, and of the relative frequency and mortality of this class of injuries in other campaigns. The information contained in Table V has been cited by many authors, with scanty acknowledg- ment. and usually with slight, but not advantageous, alterations. I agree wffth Dr. Fraser and Dr. Neudorfer {Ilandhuch dcr Kriegschirurgie, Leipzig, 1867, 8. 553) that tlie 153 chest w’ounds of the first period in the Crimean war should be added to the summary, and have, accordingly, added them in the statement in the text. “ Table IV . Statistics of AVounds of tiik Chest. I'otal JVumher of all Wounds, 1’2,094, in the Crimean War. WOUNDS. Cases. Per Cent. TO lOTAL KUMBEIl WOUNDED. I’erceritage of all chest wounds to total number 474* 3.00 wounded. Percentage of actual lung wound to total number 164 1.35 wounded. IMortality of all chest wounds to total number 135 1.11 wounded. JMortality of actual lung wound to total number 130 1.07 wounded. TO TOTAL STRENGTH. Percentage of all chest wounds 474 0.54 I'ercentage of actual lung wounds 104 0.17 Mortality of all chest wounds 135 0.14 INIortality of actual lung wound 130 0.13 I Mortality of all chest wounds . . . I Mortality of actual lung wound. Cases. 474 164 Deaths. 135 130 Per Cent. 28. 50 70. 26 * To this number ought properly to be added 153, being the number of chest wounds received during the first period of the war, of which 32 are reported to have died, making a graml total of 627 ; but, as the data for the first jieriod of the war is uncertain, the number has not been admitted into the calculation. Table V. Showimj the A’umbcr of Chest Wounds on the occasions named, a7i(l from the Authorities quoted, with the Fercentage of Deaths to Wounded. ACTIONS, Etc. Wound. Died. Per Cent. The Director-General's Records prior to 39 27 70.00 Crimean War. Crimea 474 135 28.50 Sympheropol (Russians) 200 197 98.05 Toulouse 106 50 50. 00 Quebec 26 2 7.07 Carlist War 29 27 100. 00 Paris, 1830 20* 10 50.00 Paris, 1848 9 4 44. 00 Paris, 1850 H 5 45. 30 Battle of Kilet 21 11 50.00 Battle of Idstedt 97 17 17.00 Battle of Canton 4 4 100.00 M. Meniere 20 20 100. 00 M. Legouesl 6 3 50.00 Guy’s Hospital Reports 72t 9 12.50 Danish War; Report of Chief-Surgeon 10 2 20.00 Schytz. Total wounded, 227. Dr. Kidd 36 24 66.00 Aggregate - . 1,180 547 * De Lumballe and Baudeiis. t Of (his number, the lung was really wounded in two cases only.’ Sfxt. IV.] RELATIVE EREQUENCY OF CHEST WOUNDS. 603 J. A. Liclell, U. S. V., lias already been recorded.^ On the morning of March 25th, 1865, he examined forty -three bodies of soldiers killed in the combat near Fort Steadman, in the lines before Petersburg; twenty-three were shot in the head, fifteen in the chest, and five in the abdomen. “ The bodies of all those wounded in the abdomen were very much blanched, as if they had died of hgemorrhage, and the same remark held true in regard to all but two or three of those wounded in the chest.” On the evening of March 14th, 1862, I examined the bodies of nearly all of those killed before New Berne, and ascer- tained the seat of injury, and in subsequent engagements of the Ninth and Eighteenth Corps, in North Carolina, I augmented this list to an aggregate of seventy-six observations of the bodies of those slain on the field. The mortal wound was in the head in twenty- seven ; in the neck in four, including two in which the ball lodged in the cervical spine ; in the chest in thirty-two, the heart or great vessels being perforated in eight, at least ; in the abdomen in nine; in the extremities in four. In one of the last division, the femoral artery was cut nearly across ; in another the thigh was torn completely away by cannon shot ; and in the two others, there was frightful comminuted fracture of the upper part of the femur from large projectiles. In the carefully compiled statistics of the New Zealand War of 1863-5,^ the chest wounds in a total of wounded of four hundred and sixty-three, numbered again about one in twelve; and in one hundred and eighteen cases, in which the region of the body wounded, in men killed outright on the battle-field, was accurately ascertained, the mortal wound was found in the head in forty, the neck in four, the chest in fifty-nine, the abdomen in eleven, the thigh in four ; the chest wounds equalling in numbers all the others. General-Arzt F. Loeffler reports^ the seat of injury in three hundred and eighty-seven Prussians killed in the Danish War of 1864. The chest wounds numbered one hundred and seventeen, or about one-third. That of those killed in battle, from one third to one half, and of those, wounded in action, one twelfth, receive wounds of the chest, may be accepted as very near the truth. * Surgical licport in CIRCULAR KO. 6, S. G. O., 1865, p. 29, and Libell, On the Wounds of Blood-vessels^ etc., already cited, New York, 1870, p. 12. ^MOUAT, J., Special Report on Wounds and Injuries received in Battle in the New Zealand TFar of 1863-4-5. Extracted from the Medical and Surgical History of the New Zealand 'War, London, 1867, in Volume VII of the Statistical, Sanitary, and Medical Reports of the Army Medical Department, presented by Director-General T. G. Logan. Of 463 wounded, 38 or 8.2 per cent., received wounds of the chest, or about 1 in 12. 3 1 venture to quote entire Dr. Loeffler’s invaluable table, from his GcnerahBericlit iiber den Gesundheitsdienst ini Feldzuge gegen Bdnemark, 1864, Berlin, 1867, Erster Theil, S. 46: INJURED REGION. • PRUSSIANS. DANES. Total killed and , wounded. Killed. Wounded. Died of Wounds. Total of killed and died. Total wounded. Fatal. C 3 ^ o 'goo Died later. i Total died from wounds. Died within 24 hours. Died later. Total died. Head 468 196 272 13 12 25 221 120 8 14 22 48 8 40 3 1 4 12 26 o o Chest 254 117 137 20 37 57 174 113 15 61 76 Abdomen and Pelvis 147 44 103 34 25 59 103 89 31 26 57 fjpinc and Back 39 7 92 3 24 27 34 80 6 26 32 610 2 608 o ' 51 53 317 62 ()2 Lower Extremities 720 13 716 7 83 90 103 _ 458 6 140 146 Aggregate 23.55 387 1968 82 233 315 702 1203 66 331 397 604 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, » Mortality of Woxmds of the Chest . — Great diversity of opinion Las existed and still exists as to tlie comparative fatality of chest wounds. With the data mow available an approximate solution of this problem should be attainable, and I propose to offer facts that must, if not controverted, determine the question, from the statistical point of view. If we assume the relation of chest wounds to the aggregate of wounds to be about one in twelve, or 8.3 per cent., we find, in the first place, that the mortality of chest wounds greatly exceeds the average. Dr. B. Klebs^ made autopsies in the cases of all those who died in the military hospitals at Carlsruhe, in August and September, 1870, from the consequences of w’ounds and operations. Of one hundred and twenty-nine autopsies, twenty were in deaths from wounds of the chest, or 15.5 per cent. On the other hand, the proportion of recorded survivors after chest wounds is much less than the average. The United States Commissioner of Pensions" reports seventy-six thousand four hundred and sixty-nine pensioners on the rolls on account of injinies of all sorts, of which three thousand seven hundred and thirty, or one in twenty, or 4.8 per cent., are pensioned for the results of injuries of the chest. Professor Adolph Hannover,^ of Copenhagen, informs us that the number of Danes pensioned for wounds, after the war of 1864, was fifteen hundred and eighty-eight, of whom only fifty-nine, or 3.7 per cent., had received wounds of the chest. Dr. George WilliamsoiP states that of the six hundred and three wounded soldiers that arrived in England after the India Mutiny, only nineteen, or 3.15 per cent., had received chest wounds. Pegarding the mortality of penetrating wounds of the chest in recent wars, I have been enabled to collect the following information : In the New Zealand War,^ the fatality of gunshot wounds of the lung was 60.8 per cent. In the French army in the Crimea, the fatality of gunshot wounds of the chest known to have been penetrating was 91.6.*^ In the British army in the Crimea,'^ the mortality of six hundred and twenty-seven chest wounds was 26.6 per cent. ; of one hundred and sixty-four actual lung wounds, one hundred and thirty, or 79.26 per cent., were fatal. ‘Klebs. Beitrd^e zur Pathologischen Anatomic dcr Schusswunden, Leipzig, 1872, S. 4. Dr. Klebs observes that the hospitals contained less than the usual proportion of those wounded in the head, chest, and abdomen, the graver cases being left in hospitals nearer the battle-field than Carlsruhe. ^Bakek, J. II. Report of the Commissioner of Pensions to the Secretary of the Interior, for the year ended June 30, 1871, pp. 6, 20, Uon. J. 11. Baker slates that the injuries include “all the forms incident to the life of a soldier, but so largely predominant are gunshot wounds that practically they might have been so classed.” The chest wounds arc separated in the report into external and internal, and 2,507 of the former, 1,223 of the latter constitute the aggregate of 3,730. 3 IIaxkoveu. Die Ddnischen Invaliden, Berlin, 1870, S- 8. The proportion of invalids wounded in the chest is as 1 in 26. WILT.IAMSOX. Military Surgery, London, 1863, p. 237. Two of the nineteen died shoi-tly after arrival. See Specimens 3637, 3638, and 3669 in the Kctlcy Collection, and Plate IT, p. 86, of Dr. Williamson’s work. The proportion of th<;sc surviving chest wounds temporarily was as 1 in 31.7% ® In the New Zealand War, Inspector-General Jlouat {op. cit., Vol. vii, p. 485) reports thirty-eight cases of gunshot wounds of the chest. Eleven were wounds of the muscles, one of the bones, three penetrated the chest w’ithout entering the lung. Of these fifteen patients, twelve resumed duty and three were invalided. Of twenty-three wounds of the lung, fourteen were fatal, eight patients were invalided, and one returned to duty. The mortality rate for all cases was 36.8 per cent., for the penetrating lung wounds 60.8 per cent. Dr. Mount’s report contains a synopsis of the prominent points connected with the twenty-three cases of wounds penetrating the lung ; of seven additional cases of penetrating gunshot ■wounds of the chest (wounded Jrlaori prisoners), six resulted fatally. M. CllEXU (op. cit., p. 187). From the total of 2,818 classified as chest wounds, arc to be abstracted 212 sabre and bayonet wounds and 333 miscellaneous injuries, 538 gunshot contusions with 62 deaths, a mortality of 11.5 per cent., and 576 undetermined gunshot chest wounds with 1C4 deaths, or 28.4 per cent. There remain 1,159 cases, of which 668, with 87 deaths, were non-penetrating, a mortality of 12.0 per cent., and 491, with 450 deaths, or 91.6 j)or cent., w’cre penetrating, ^ f-lATTHEW {op. cit., Vol. II, p. 313) tabulates only the 474 cases cf the second period, with 135 deaths. I have added the 153 cases with 32dcaths of the first period. The mortality cf chest wounds in the Russian army in the Crimea has not, as I am aware, been ofiicially reported. Dr. Pirogoff expresses his rcgi'ct (Grundzuge dcr Allgemeinen Kriegschirurgic, Leipsig, 1864, S. 535) that he cannot furnish any statistical data, and quotes from Demme and Ctromeycr. It is stated by Mount that, at SjTnpheropcl, the Russians had 200 patients with gunshot wounds of the chest, cf whom 197 died. 'Phe xSardinian army had but few wounded in the Crimea, 193 in all ; of whom 10 w’crc killed and 16 died of wounds, according to the table cf Dr. Comisetti, jn’esident of the Health Board of the .Sardinian Army. Tlie effective force of the army was 21,000. Skct. IV.] MORTALITY OF CHEST WOUNDS. 605 In the Italian War of 1859, Demme^ reports four hundred and eighty-four superficial, and one hundred and fifty-nine penetrating, gunshot wounds of the chest ; forty-three of the former and ninety-seven of the latter died in liospital, or mortality rates of 8.8 per cent., and 61 per cent. In this war, the early mortality, at any rate, from such injuries among the Frenclr was much less, amounting to only 46.48 per cent, even for the pene- trating gunshot wounds alone. In the first Schleswig-Holstein war,^ after the battle of Idstedt, Dr. Stromeyer lost but 17.6 per cent, of patients in the Hanoverian army with gunshot wounds of the chest. In the Danish War of 1864,^ the mortality of all gunshot chest wounds was, among the Prussians 41.6 per cent., among the Danish prisoners 67.2 per cent. In the Six-Weeks War, Dr. Maas^ reports twelve gunshot wounds of the lung, with only four fatal cases, or 33.3 per cent. Dr. Stromeyer,* *^ at Langensalza, had but sixteen recoveries in forty-seven penetrating gunshot wounds of the chest, a death rate of 65.9. Dr. Biefel,’ at the hospital at Landeshut, in Silesia, had forty-four cases of gunshot wounds of the chest, of which fifteen were penetrating. The twenty-nine cases with superficial wounds recovered. Of the remainder, eight, or 53.3 per cent., died. From the Franco-German AVar, numerous partial returns have already been received. At Mannheim and AVeissenburg, Professor Theodor Billroth® lost but nine of thirty patients with penetrating gunshot wounds of the chest. At Aletz, Dr, H. Fischer® reports the proportion of fatal gunshot wounds of the chest at 55.8 per cent. After Sedan, Mr. MacGormac reports^® the mortality of penetrating gunshot wounds of the chest at the Anglo-American Ambulance at Asfeld, as 54.8. At the field hospital a,t Floing, Generalstabsarzt StromeyeP^ had fourteen cases of penetrating chest wounds, seven of whom were likely (September 26th, 1870) to recover. * Demme, ^illgemeine Chirurgie der Kriegswunden^ Wurzburg", 18C4, S. 90. Demme reports in all two hundred and three cases of penetrating gunshot wounds of the chest; but states that forty -four were without injury of the viscera. He gives his farther statistics from the one hundred and fifty-nine remaining cases and drops the forty-four cases. This is one of the many careless errors in Demme’s statistics, of which Dr. Loeffler justly complains. They abound in the second edition, of 1863, fur which reason, I quote usually from the edition of 1861. *31. Chexu {op.cit. T. II, p. 474) tabulates one thousand fifty-two chest wounds; deducting thirtj'-seven sabre, bayonet, and lance wounds, and two hundred and four miscellaneous injui'ies, there remain eight hundred and eleven gunshot wounds distributed as follows: contusions forty-eight, with seven deaths; fractures one hundred and twenty-eight, with twenty deaths ; contused wounds three hundred and seventy-nine, with four deaths; penetrating wounds two hundred and fifty-six, with one hundred and nineteen deaths, or 46.48 per cent. * July 2Cth, 1850. Dr. Stromeyer had seventeen deaths in ninety-seven patients with chest wounds, in a total of twelve hundred and ten wounded. Maximen der Kricgsheilkunst, S. dS."). '* Lceffleu {lo:. cit.) From the table quoted, compiled with a precision unattainable except in a population where every' individual is registered, it appears that of twenty -three hundred and fifty-five killed and wounded Prussians, two hundred and fifty-four, or one in 9.27, received wounds of the chest. One hundred and seventeen of the two hundred and fifty-four fell dead; of the one hundred thirtj^-seven remaining wounded, fifty-seven died in hospital (twenty within forty-eight hours), or 41.6 per cent. Among twelve hundred and three wounded Danish prisoners, one hundred and thirteen, or one in 10.6, had chest wounds, of which seventy -six, or 67.2 per cent., proved fatal. Dr. Lcefiler gives us the assurance, which, in his case, is unnecessary, that the larger mortality among the prisoners was not due to any ditference in the treatment received by the prisoners. Professor Pillroth justly extols the statistics of Dr. Lcefllcr, as examples of the exactitude possible in large consolidated surgical statements. I regret that I cannot refer to the second part of Dr. Lceffler's work, which doubtless separates the penetrating from the non-penetrating chest wounds, and gives the ulterior mortality. ®3Iaas. Kriegschirurgische Beilrdge, S. 72. ®Sth0MEYEU. Erfahrungen uber Schusswunden, S. 42. * Biefel. Im Reserve Lazareth. Kriegschirurgische Aphorismen, von 1866, in Langenbeck’s Archiv fiir Klinischc chirurgie, B. XI, S. 369. ®Billu0TH {Chirurgische Brief e aus den Kriegs-Lazarethen in Weissenburg und Manniieim, 1870, Berlin, 1872, S. 192) reports that of tliiify cases of penetrating wounds of the chest, nine, or 30 per cent., died, a result so much more favorable, as se^ral of the fatal cases (cases 3, 12, and 26) might be excluded on account of severe complications with other injuries, and as one of the wounded, a convalescent, fifty-seven days after tho injury’, was attacked by typhus and died in consequence. ®FisCHEn, II. {Kriegschirurgische Erfahrungen^ ^rsXer Theil, vor Erlangen^ 1872, S. 116) says: “Seventy-eight gunshot wounds of the thorax were treated, and of these, thirty’-four, or 43.5 per cent., were perforating. * * Of the seventy-eight cases of gunshot w'ounds of the thorax, nineteen died, or 24.3 per cent. The fatal cases were all in consequence of perforating wounds, of which latter class therefore 55.8 per cent, died.” Dr. Fischer adds: “Beally' remarkable is the fact that Billroth lost only five of thirty cases of this kind, or 16.6 per cent., as his mode of treatment varied little fi-om that usually employed.” If Dr. Fischer deducts the three cases of amputation and one of typluis from the mortality’, he should deduct them also from the aggregate, which would leave twenty-six cases with five fatal, or 19.2 per cent. But it will hardly be claimed that this constituted the entire ultimate proportion of mortality. 3lA('ConMAC {op. cVf., p. 126). Of fifty-four wounds of the chest treated, thirty'-onc were regarded as penetrating, of which seventeen terminated fatally'. Ibid., p. 122. Tliere were at this Feld-Lazarcth one hundred and twenty’-onc patients — sixty-four Cicrmans, fifty -seven French. 606 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V, Regarding the mortality of wounds of the chest in the War of the Rebellion, we have the data afforded by Table XXV, p. 600, giving the gunshot wounds of the chest for nearly all of the Union soldiers during the last year of the war. Of three thousand nine hundred and seventy patients with superficial wounds, fifty-four died, or 1.3 per cent. ; of three thousand two hundred and three with penetrating wounds, one thousand and seventy died, or 33.4 per cent., a total number of chest wounds of seven thousand one hundred and seventy-three, with one thousand one hundred and twenty-four deaths, or 15.6 per cent. Rut the Endrcsidtat does not appear in this computation, and we must have recourse to the aggregate of cases of penetrating wounds of the chest collected from the returns of the general as well as the field and primary hospitals. These results are set forth in the following statement (Table XXVI), which includes the cases of Confederate j^i’isoners as well as of Union soldiers ; Table XXVI. Numerical Statement of Eight Thoumnd Seven Hundred and Fifteen Cases of Penetrating Gunshot Wounds of the Chest reported on the Returns during the War. CHARACTER OF WOUND. Cases. Deaths. Discharged. Duty. Undeter- mined. Ratio of Mortality. Missile entered and passed out, traversing tlie cavity of the thorax. i GO 1,011 1, 352 403 16 36.5 Missile entered the thoracic cavity and was believed to have lodged within it .* 484 243 189 48 4 50.6 Missile stated to have penetrated the cavity of the chest without specification as to lodgment or exit 1,780 1,348 65 299 68 78.7 Missile entered and wounded lung without specification as to lodgment or exit 1,G83 1,192 110 266 115 76.0 Cases described as severe gunshot jienetrating wounds of the 1, 304 1,214 90 100. Missile impacted between the ribs, but external to the pleural 0 1 1 100. Missile fracturing and depressing ribs but not itself entering the thoracic cavity 446 68 176 186 16 15.8 Missile perforating chest and wounding both lungs 58 47 7 2 2 83.9 Missile j>enetrating aiul wounding diajdiragm 8 8 100. 121 89 31 1 74.2 AVilh wounds of the intercostal and internal niannnarv arteries... 21 17 4 80.9 10 6 4 60.0 AVith wound of the heart 12 11 1 91.6 3 3 100. With wound of the vena cava 1 1 100. 1 1 100. Aggregate 8,715 5,260 1, 939 1,204 312 62.6 One thousand five hundred and sixty-five Confederate cases are included in the state- ment in Table XXIV. Seven hundred and fifty had received non-penetrating, and eight hundred and fifteen penetrating, wounds of the chest. Twelve of the first group died, and four hundred and seventy-eight of the second group. In the second group, two hundred and seventy-one recovered, and sixty-six were returned before convalescence, and their ultimate fate is unknown. The mortality rate for the determined cases of penetrating Sect. IV.] MORTALITY OF CHEST WOUNDS. 607 gunshot wounds of the chest in Confederate soldiers is therefore 63.8 per cent., or very little more than the mortality of the Union soldiers. These facts are taken mainly from the registers and case-books of Confederate hospitals, or from printed sources of information, or from the registers of Union hospitals in the cases of Confederate prisoners. In the latter group the mortality rate is but slightly above the average, an unexpected result, as the depressing effect of defeat and of confinement among strangers are usually more manifest in the comparisons of mortality, as strikingly shown in the excessive mortality among the Danish prisoners, as pointed out by Dr. Loeffler [loc. cit., p. 56). Of course there is usually a large proportion of the graver injuries among prisoners, and a somewhat larger mortality is to be anticipated. Abstracting the eight hundred and fifteen Confederate cases, and the two hundred and forty-six undetermined Union cases from the statement of eight thousand seven hundred and fifteen penetrating chest wounds included in Table XXVI, there remain seven thou- sand six hundred and fifty-four determined cases of Union soldiers, with four thousand seven hundred and eighty-two deaths, or 62.4 per cent. Apart from that furnished by the hospital registers, little statistical material on this subject, as regards the Confederate army, is accessible. The paper by Surgeon Thom, read at Richmond in 1864, would be valuable if correctly printed, and it is to be desired that the author may revise and publish it in fulfil Surgeon C. Terry” reports, from the battle of Chickamauga, six cases of penetrating gunshot wounds of the chest, with four recoveries; and Surgeon D. C. O’Keefe^ publishes five cases with only one fatal result. Examples of recovery after injuries of this nature are also cited by Surgeons Selden, Thom, Read, Baruch, Michel, and Browne.^ All of them are included in my estimates. ^ Among the Confederate writers, Dr. E. Warren (op. cit., p. 370) obser^'es that “wounds of the lung are far from being so fatal as might be supposed in advance. Numerous cases have come under my own observation, during the present w’ar, in which rapid recoveries have followed the most severe penetrating wounds of this delicate organ. The experience of Confederate surgeons will confirm the assertion that unless death speedily results from luemon-hage or collapse, a favorable prognosis may be formed in a majority of such cases.” The writer docs not indicate the degree of fatality which might be errone(»usly “supposed in advance,” nor describe the numerous recoveries he has witnessed after the most severe lung wounds, and the recorded experience of Confederate surgeons invalidates instead of confirming the assertion that the majority of severe lung wounds get well. Dr. J. J. Chisolm (op. cit., p. 310) says: “Wounds of the chest, when taken as a class, are, perhaps, the most fatal of gunshot wounds. * * Should the lung be severely injured, the case usually terminates fatally.” fben relates some remarkable examples of recovery, and adds: “In our experience, penetrating wounds of the chest, even those in which the ball had clearly traversed the lung, are, by no means, so fatal an injury as gunshot wounds of other regions of the trunk.” The apparent contradiction is avoided by the limitation of the comparison to wounds of the abdomen, pelvis, and spine. “Under the expectant plan of treatment,” Dr. Chisolm continues, “ which consists of little more than careful nursing, avoiding all active treatment, more especially bloodletting, we have succeeded in saving a majority of our wounded. Surgeon Thom, in a recent report to the association of army and navy surgeons, give.s a list of seventy-four cases of gunshot wounds perforating the chest and transfixing the lungs, as reported by Confederate anny surgeons. Of these, twenty died, — a mortality of 25 per cent., — which indicates clearly the advantages of the expectant course of treatment for this as well as for all gunshot wounds, over the heroic and fatal treatment of former years. As far as could be ascertained, bloodletting had been resoried to in but one case of perforated chest wounds.” On referring to the abstract of the report of Surgeon Thom, chairman of the committee on gunshot wounds of the chest, as printed in the Transactions of the Association of Army and Navy Surgeons, at page GO, of the April, 1864, number of the Confederate States Medical and Surgical Journal, it is found that, after a preliminarj' dissertation on “the general treatment of injuries of the lungs from missiles, penetrating and cutting weapons; the time and manner of death under such circumstances; the pathological condition, functional embarrassment, or usefulness remaining after these accidents ; the mode of production and treatment of emphysema ; and the provisions made by nature for accommodating foreign bodies retained within these organs, with the amount of disturbance which ensues,” Dr. Thom “regretted that few replies had been received to the interrogatories which the preparation of this report had suggested, and that he could furnish only seventy-four cases of gnnshot wounds of the lungs, in which twenty recovered, from which limited number it appeared the mortality was little over twenty-five per cent., or one-quarter. As far as could be ascertained, bleeding had been resorted to in but one case, and that recovered.” If twenty of the seventy-four cases related by Dr. Thom “recovered.” the mortality was 72.9 per cent, and not “a little over 25 per cent.” It may be that there is here a clerical or typographical error, and that the writer meant to convey that twenty cZied, as Dr. Chisolm interprets. But the contradiction destroys the statistical value of the report. "Were it otherwise Dr. Chisolm’s assumption, that the mortality of 25 (27.2?) per cent., as given in this paper, represented the results of Confederate experience of the danger of gunshot wounds transfixing the lung, would be untenable; and his claim that this startling result was due to the advantages of expectant over depleting treatment is XTnexpccted from a surgeon usually Tareful and accurate in his statements. I do not yield to Dr. Chisolm in deprecating the employment in chest wounds of the depleting measures of former years, still advocated by Professors Gross and Erichsen and Stromeyer; ])ut to maintain that e.xpeetanoy or any mode of treatment can reduce the mortality of lung wounds fifty per cent, is to advance a proposition too cgrcgiously imj'robablc to be discussfed. One may hope that it was througlj inadvertence, and not to sustain his argument, that Dr. Chusolin, in quoting Dr. Thom’s allusion to the single case of venesection for lung wound, omitted the words “and that recovered.” I have had the files of the Richmond and Louisville Medical Journal, the Confederate States Medical Journal, the American Practitioner, the Nashville Journal er lobe G 4 j Middle lobe 5 0 Eiyht Lunff j Lower lobe 3 0 ^^Not ascertained 5 5 f Upper lobe 12 3 J Middle lobe 9 4 Left I/any 1 Lower lobe 7 3 (Not ascertained G 5 BothlAinys . . - Not stated 2 2 Total 55 2G 610 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V A false interpretation of some of the statistics generally quoted by systematic authors is one of the causes that have led practitioners to form too low an estimate of the gravity of wounds of the chest, a cursory and partial examination of the figures leading to conclusions very different from those which the author thought to establish. Thus, Guthrie, who fully appreciated the fatality of penetrating gunshot wounds of the chest, cites [Comm., p. 462) one hundred and six such cases after the battle of Toulouse (see Table V, p. 602), remarking that the cavities were not penetrated in all. In seven weeks thirteen had recovered, thirty-five had died, and fifty-seven “ were transferred to Bordeaux to proceed to England, some to die and some to be pensioned, but few, in all probability, to return to the service, an ultimate loss of nearly one-half, if the cases sent to England could be traced.” But they were not traced, and it is a mere assumption to put the percentage of mortality at 50, as even Dr. Fraser has done.’- Otlier causes of the inadequate appreciation of the gravity of wounds of the lung are the prominence given to exceptional cases of recovery after very severe injuries of the chest and the interest they naturally awaken,^ and also the comparative frequency of examples that are to be met with in authors of recoveries after perforations of the chest by the rapier or bayonet, or by small pistol balls. ^ Confining their attention to a limited number of cases, some writers are betrayed into the error of regarding the latter group of injuries very lightly."' * The ancients were less sanguine than the modems in this matter. Galen (Lib. V, cap. 26) pronounces deep wounds of the lungs fatal. John Tagaultsays (Institutionum chirurgicarum Lihri Quinque, cd. Uffenbachii, Francofurti, 1610, Lib. II, c. iii, p. 736); “Vulnera autem quae pulmonibus incidunt, ideo curatu sunt ditlicillima, imo magna ex parte insanabilia ; quoniam promptissime phlegmonem excitant.” IliCHARD Wiseman {Severall Chirurgical Treatises, (London, 1676, Book VI, c. viii, p. 434 and p. 436) writes “almost all thcise wounds made by gunshot arc mortal,” and “many instances may be giyen of gunshots in the breast, but few do recover that are shot in the lungs. Plenck says {lastit. Chirurg., 1774) “Magna pulmonis vulnera absolute lethalia sunt.” 2 In reading the history of Maiden's case {An Account of a case of Recovery after the Shaft of a Chaise had been forced through the Thorax, Lijndon, 1824, 4‘«), many readers do nut pause to reflect that the i)reparation in the Royal College of Surgeons indicates that the lungs were not wounded, and that it is believed that the foreign body passed between the ribs and pleura. Dr. THOM {loc. cit., p. 60) relates a somewhat similar case of recovery on the authority of Dr. Semple, though it was assumed that the gig-shaft, in this instance, “passed entirely through the right lung.” The sequel of the yet more marvelous case of the Prussian sailor, John Taylor, impaled by a try-sail mast, treated at the London Hospital by ANDREWS, in 1831, is related in 1857 by Dr. A. C. Garuatt, of Massachusetts {Boston Med, and Surg. Journal, Vol. LVII, p. 488), who, on a voyage to Liverpool, enncountcrcd this man in perfect health, twenty-six years after the reception of his injury, with a large depressed semi-lunar cicatrix over the region of the heart, the organs of the chest on auscultation and percussion being perfectly normal. Dr. Garratt took the man to London, where he was recognized by Professors Partridge and Fergusson, and appointed janitor of the Museum of the London Hospital. 3 T’hus Dr. F. 11. Hamilton {Principles and Practice of Surgery, 1872) announces that “pistol balls, with small shot, seldom prove fatal when lodged within the chest, unless from wounds of the heart or great vessels.” In sixteen cases of fatal penetrating gunshot wounds of the chest reported in the Army during the i>ast five years (Circular No. 3, S. G. O., 1871, A Report on Surgical Cases treated in the Army, etc., p. 29), three (Cases LXXVII, LXXXl, LXXXV) were instances in which a pistol ball or bird shot lodged within the chest without injury to the heart or great vessels. Of the first fifteen hundred cases of penetrating gunshot wounds of the chest entered on the registers of the late war, thirty-three were inflicted by pistol balls. Twelve of these were fatal. In six cases the ball emerged, in four it lodged within the thorax, in one in the glenoid cavity, in one this point is not noted. ** Thus Surgeon Middleton l\Iichel, P. A, C. S., adduces {Confederate States Medical and Surgical Journal, p. 102), in his dissertation on “healing of gunshot wounds by first intention,” illustrations of cases of rapid recovery after transfixion of the chest by the bayonet at Spottsylvania. He writes “ That such prompt cicatrization occurs after punc^tured wounds, which depends, doubtless, upon the rapidity with which the track closes, through the elasticity of the separated tissues, I had several opportunities of ascertaining during the memorable fights of the 11th and 12th of May. In that remarkable assault on our breastworks, ten lines deep, in which the enemy exhibited unwonted boldness, and a persistent constancy of purpose only interrupted by night and only terminated by a disastrous repulse, a bayonet charge ensued which presented us with this class of wounds fur the first time. Through the courtesy of my friends, Surgeon L. Guild, Medical Director of General Lee's army, and Surgeon J. T. Gilmore, Chief Surgeon of McLaw’s division, and Surgeon r»aruch, 3d South Carolina battalion, I examined several whose chests liad been entirely transfixed by the bayonet, and who were all doing well. Their wounds healed in less than forty-eight hours ; two had expectorated a little blood, but careful auscultation could detect no abnormal sounds; there was but little pain present, and no cough ; no hcemorrhage of any account from the wound had been remarked. Tlic men were seated up in their tents on the fourth day, eating, and the cordiiorm and punctured wounds, indicating the heel and point of the bayonet, already healed, were well defined on the respective sides of the chest.” It may be inferred that two of tlie cases mentioned are the same cited by Surgeon Baruch, 3d South Carolina battalion, at page 133 of the same Journal. These cases {Finlder and Percival) are noted on page 470 cf this chapter, tlxe reference to Dr. Baruch’s paper being inadvertently omitted. Dr. Baruch is positive that the right lung was interested in Finklcr’s case, though the hcemoptysis was the only symptom of lung wound, and auscultation gave negative results. He is less confident in Fcrcivars case: “ When brought to the Infirmary, his countenance was pale and did not wear that expression of anxiety so peculiar in penetrating wounds of the chest ; his symptoms indicated a shock to the nervous system, induced by the intense excitement of a hand-to-hand conflict with the drunken and infui’iated foe.” (“He was lying on his abdomen and partially on his left side behind a small rail-pile, when he was transfixed” is the immediately preceding statement.) “Acting on this supposition,” Dr. Baruch "administered some stimulants and anodynes, which partially restored the patient, and enabled him to recite his encounter with the enemy.” * ** * “There was but slight dyspncea, no cough, and but little bloody expectoration, indicating that the injury to the lung was not extensive. A careful investigation of the posture of the patient daring the reception of the wound convinced me that the weapon grazed the right border of the posterior portion of the left lung, passing through the posterior mediastinum and evading the heart, which was dis]>laced by the patient's lying on the left side.” If the reader cannot thread his way through the labyrinth of breastworks “ten lines deep,” nor determine Sect. IV.] COMPLICATIONS OF INJURIES OF THE CHEST. 611 Complications. — The punctured, incised, contused, and gunshot wounds and injuries of the chest that have been examined, with some features in common, present so many differences that their classification is difiicult. Though arranged for convenience as non- penetrating and penetrating wounds and injuries, this distinction by no means indicates their extent or gravity, — an innocuous puncture with a capillary trocar falling in the latter order, and ruptures of the heart or laceration of the lungs without external wound in the former. A division into injuries of the walls and of the contained viscera is not more favorable to strict definitions. It has therefore been necessary to consider these injuries according to the particular structures they involve and the complications to which they give rise. The latter may be divided into primary and consecutive. The primary com- plications are hsemorrhage, emphysema, and pneumothorax, hsemothorax, fractures of the bony and cartilaginous case and of the clavicle and scapula, hernia of the lung, and the lodgement of foreign bodies. The consecutive complications are intermediary haemorrhage and heemothorax, pleurisy, hydrothorax and empyema, pneumonia, abscess of the lung, carditis and pericarditis, erysipelas, gangrene, tetanus, pyaemia, secondary emphysema, fistula, and contraction of the side of the chest. Hcmiorrliage . — Bleeding in wounds of the chest is primary, intermediary, or, rarely, secondary, and proceeds from the superficial arteries, the intercostals, and mammaries, the pulmonary substance, the coronary arteries, and the heart and great vessels. Serious bleeding from superficial chest wounds was uncommon, yet, as mentioned in a note on page 519, the minor vessels sometimes bleed alarmingly after gunshot wounds. This is noted in only six cases, of which two were fatal of the eleven thousand five hundred and forty-nine cases classified as non-penetrating gunshot wounds of the chest. When the bleeding is not readily arrested by cold water and compression, the safe rule of exposing the bleeding vessel and placing ligatures above and below the wound should invariably be followed, without trifling with styptics. Mention has been made of many wounds in the subclavian and axillary regions, in which the vessels were implicated.* In such cases, if the vessels were largely opened, immediately mortal haemorrhage ensued. If the wound was narrow, or the orifice in the vessel obstructed by a foreign body, or the bleeding partially arrested by compression, a diffused aneurism formed. If the haemorrhage was in a great measure controlled by pressure and plugging, the extravasation of blood resulted consecutively in a circumscribed aneurism. The results of ligating the proximal end of the main trunk were deplorable, and, in their discouragement at the want of success in ligations after wounds of the upper portion of the axillary, some surgeons regard it as most prudent to await the formation of an aneurism, and to practice an ulterior operation. But, whenever it is within the range of possibility, both ends of the injured vessel should be tied. It is very difficult to which party was repulsed, he will at least think it probable that Finkler and I^ercival (whose heart was providentially displaced into the jiosterior mediastinum) were two of the sufferers, although he might not agree with Dr. Michel that the cases furnished an analogy for the liealing of gunshot wounds by first intention, or partake of Dr. Baruch’s conviction of the innocuity of bayonet wounds. “The limited experience derived from the treat- ment of these cases induces me,” writes Dr. Baruch “ to consider bayonet wounds as very simple injurie.s.” * * This dread of cold steel is, in my humble opinion, mainly attributable to ignorance of the nature of the injuries inflicted by it. There appears to exist in the minds of men a vague dread of transfixion by the bayonet. But this would not be so were it generally known that bayonet wounds are almost harmless when compared with the ploughed tracks which the tenible mini6 bores through the tissues.” * * “A bayonet wound almost invariably heals by first intention under auspicious circumstances.” * * “Why i.s it that soldiers have such a wholesome dread of tlie bayonet?” Hknnen* tells us (pj). cit. p. 374) that “ bayonets passing along or through the muscles covering the chest and its vicinity, demand a peculiarity of attcntiiJii, solely from the danger of inflam- mation spreading to the pleura, or the lungs and heart, or of troublesome abscesses forming. In this view, the very slightest arc interesting, and sometimes highly dangerous, particularly in persons disposed to pulmonic affections.” have followed M. Legouest in including these lesions with wounds of the chest, a classification which, 1 think, presents many advantages.— COiU’lLKR. 612 WOUNDS AND INJUEIES OF THE CHEST. [Chap. V, clistinguisli tlie bleeding I'rom tlie subscajmlar and circumflex Iwanclics from tliat of the main vessel, the degree of hsemorrhage and the cessation of the radial i)ulse being about the only signs to aid in the diagnosis. Wounds of the subclavian and axillary veins were controlled, in a few instances, by compression. In these injuries and in the operations which they require, the surgeon is confronted with the danger of the entrance of air into the vein, a subject which Wepfer, Bichat, and Nysten, and, in this country, J. C. Warren, have particularly called attention.^ Simultaneous lesion of the axillary artery and vein gave rise to aneurismal varix in three cases of incised wounds recorded by D. J. Larrey.^ This condition may result likewise after gunshot wounds, as was observed by Dupuytren and rejiorted by Bcrard.’^ A case of successful ligation of the subclavian for aneurism reported l)y I)r. Josiah 0. Nott,^ in 1841, is also cited as arterio-venous in its character. Dr. J. P. 0. WederstrandD also reports an aneurismal vmlx following a gunshot wound of the sul:)clavian vein and artery, which the patient survived seven years, when he died from an intercurrent disease. M. LegouesD details a case resulting from a musket ball wound in the left axilla, at Balaclava. In the eight thousand seven hundred and fifteen cases of penetrating wounds of the chest, haemorrhage is noticed as a grave complication in three hundred and forty-six cases, of which one hundred and thirty-seven resulted fatally. In the four hundred and eleven abstracts contained in this chapter, hsemorrhage was a prominent feature in one hundred and one.’’' Enough evidence has been adduced of the dangers of lesions of the internal mammary and intercostal to prove that they are not to be discussed in the tone of levity some writers have adopted, six cases of the former and eleven out of fifteen cases of the latter having proved fatal. When the difficulties of ligating these wounds cannot be surmounted, the efficacy and security afforded by Desault’s simple mode of compression by a pouch stuffed with lint should be borne in mind. Some examples liave been given with a view to prove that hsemorrhages resulting from injuries of the subclavian, primary carotid, and even the innominate vessels, should not be regarded as without the legitimate pale of operative surgery. The brilliant cases of ligation of the subclavian by Professor Billroth,® during the recent Franco-German war, should be compared with these cases, and the. question examined anew if it is not possible to save life under these circumstances, or at least to postpone the fatal issue by operative interference. Wounds of the heart and great vessels have been already noticed, and, if space per- mitted, the pathological material in the Museum and the literature of this interesting * All the cases aiiterior to his time are cited by Mokgagni, l)e Sedihus et Cansis Morhortim, Epis. V, § 21 sqq. See MagendiE, Sur VEntrte accidentclle dc VAir dans Ics Vetnes, suj' la wort suhitc qui cn est I'rJFet, in the Journal dc JVti/siolngie Escpcrimentale^ T. I, 1821, }>p. 190-199; LEROY (d'fitiolles) Notes sur les Effets de V introduction de VAir dans le Veins, Arch. Gen. de j\l6d., 182iJ, T. Ill, p. 410, Juillet, 1824, p. 4:J0; SauceuOTTE, Des Effets j^ff^duits seu V ffconomie animalc par la Presence de VAir atmosjdicrique dans Vappareil circulatoire, Th^se de Strasbourg, 1828; DELPECII, Memorial des Ilospitaux du Midi, November, 1830 ; Langenbeck, Beitr'dfje^ zur cliirurgischcn Patliolugie der Venen, Archives, Berlin, 1861, Erster Band, S. 1 ; WATTi^rANN, Sichc7'cs lleilverfahren he.i Lnftemtriit in die Venen, "Wien, 1843. ^Laruey, I>. j., Clinique Chirurgicalc, 1'. Ill, p. 139, and TiulUtin de la FacuUe de Medccinc, T. Ill, p. 27. ^ Dictionnaire de Medccinc (cn XXX) Paris, 1833, T. IV, p, 510. ‘^NO'rr, J. C., Am. Jour, of Med. Sci., N. S., Vol. II, p. Ill, and Aimales de )a Chirurgie Eranejaise ct I^trangere, T. IV, p. 120, and London Medical Gazette, October 22, 1841, p. 158. ® AVedEUBTR.vndt, New Orleans Medical News and Hospital Gazette, 1854. ®Legoue.st, Chirurgie d'Armee, 2d ed. p. 323. ^In the twenty-three cases of penetrating gunshot wound of the lung that came under treatment in the New Zealand War (Mouat’s report, already cited, i). 15), six terminated fatally from primary, and three from intermediary, iTaunorrhage. ® Billrot h, Chirurgische Brief c u. s. w. S. >22. Professor Billroth tied the subclavian three times and assisted at two otlicr ligations for bleeding from the main trunk. One of the patients is believed to have ultimately recovered. I may liere mention that I am informed by Dr. White, of New Orleans, that he examined the patient on whom Dr. Smyth, in 1864, successfully ligated the innominata, in tlie summer of 1872, and found the man in tolerable health, though a small tumor with an aneurismal thrill, had reappeared. Sect. IV.] COMPLICATIONS OF IN.IURIES OF THE CHEST. 613 subject might be profitably reviewed.^ I can liere only refer to specimen 3388, figured on page 588, as suggesting a possible explanation of the mode in which balls and other foreign bodies may gain admission to the cavities of the heart witliout leaving any trace of wound in the walls of that organ, viz., by gradual absorption of the wall of j)ulmonary vein com- pressed by the extraneous body. There appears to be no means of accounting for the recorded facts relative to the presence of balls in the hearts of deer, hogs, etc., without the slightest evidence of any lesion of the cardiac walls. And I may mention, briefly, that Dr. Carvallo’s case® of non-penetrating gunshot wound of the left ventricle, was attended with division of large branches of the coronary artery, as in the cases recorded by Lamotte^ and Larrey.^ Haemorrhage from wounds of the smaller pulmonary vessels, and from laceration of the lung tissue will be considered under the head of hoemothorax. Emphysema . — The supervention of emphysema is noted in only thirty-eight of the eight thousand seven hundred and fifteen cases of penetrating wounds of the chest. In the four hundred and ten abstracts in this chapter, its presence is noted in seven cases only. The following is an example of this complication in which some details are related : Ca.se.— Private William H. Mansfield, Co. D, 13tli New York Cavalry, aged 21 years, was wounded while attempting to pass the line at Piedmont, October 19th, 1864, by a conoidal hall, which passed through the muscles of the left arm near the shoulder, entered the chest near the axilla, passed through the cavity, from which it emerged between the fourth and fifth ribs, and lodged beneath the integument between the scapula and the .spine. A considerable degree of emi)hysema su])ervened in tlio tissues about where the missile lodged. He was conveyed to the field ho.spital, where the hall was excised by Assistant Surgeon J. T. Burdick, 13th New Yoi-k Cavalry. Cold compresses were applied, with continuous ju’e.ssurc to the hack. Morphia and tincture of veratrum viride were freely administered. Quiet was enjoined, and the patient instructed to lay u])on his left side. He recovered, with partial atrophy of upper lobe of left lung. lJischarge{l from service in June, 186.5. Not a pensioner. fllie infrequency of this complication in the Confederate service is noticed by Surgeons Chisolm and Jefiery.^ Dr. Williamson*’ bears similar testimony from the experience of the British officers in India. But, though rare, this complication is not so uncommon as these observations would imply.’’' It is probable that, the teachings of the last generation of military surgeons having dispelled the exaggerated apprehensions with which this phenomenon was regarded, its appearance in a limited extent was not always regarded as of sufficient moment to bejipecified. Such was the influence exerted by the observations of Sauvages, Littre, Boyer, and Larrey,® that the celebrated TIennen wrote [op. cih, p. 374) that “when I first entered on the practice of military surgery, the fear of emphysema actually haunted my hours of repose.” But it has since been shown that, though a troublesome, it is not a dangerous sjunptom, and by no means a frequent one. ^ Consult the authorities cited in the note to p. 527 and refer to the preparation of Professor Theile, in the museum of patholog-ical anatomy at 15ernc, in which a laceration of the arch of the aorta was not fatal for several months after the accident; also the recent case at Carlsruhc, which Professor Billroth alludes to {op. cit., S. 113) and Dr. SOCIX describes {Krier/schirurgische Erfahrungen, u. s. w'., Leipzig, 1872, S. 48 : Lecrei>e, wounded at Worth. August Gth, 1870, transferred to Carlsruhe. * * Copious haemorrhage on the sixteenth day ; death.” 'Dr. Bcitrdgc zur path. Anal, der Schitsswunden^ Leipzig, 1872, S. 12fi, gives the notes of the autopsy made August 20th, 1870, and remarks on the slight primary bleeding. ^C'AliVALLO, p, 534, and Circular No. 3, S. G. O., 1871, p. 33, and Specimen 5929, Section I. Army Sledical Museum. ^LamoTTE. TraitA compUt de Chirurgie^ Paris, 1781, T. II, p. 09. Laruey. Clinique Chirurgicale, T.II, p. 291. ^Chisolm. {A Manual of Military Surgery, 3d ed., p. 319): “It is a sign which our extensive experience shows to be rarely present.” jEFtTiitY, 11. \V., Surgeon C. S. N. {Confederate States Med. and Surg^ Jour., vol. I, p. 39), describes a gunshot wound of the lung attended with emphysem4% in a seaman of the C. S. Steamer Isondiga, and remarks, in 1804 : “Since the beginning of the war, this is the second case of wounded lung in which, if my memory serA’cs me aright, I have seen emphysema, and in which there was no expectoration of blood.” So, also, the authors of the Confederate Manual obser\*es of emphysema: “ It is not common after gunsliot wounds, but occasional!}' happens.” ® Williamson. Military Surgery. -p. IQ •. “It is seldom that emphysema follows a gunshot wound, but is somewhat more common immediately after sword or lance wounds, but not so frequent as was formerly supposed.” ’ MOUAT. Jiritish Stat. San. and Med. Hep., 1805, Vol. VII. p. 487. In the twenty •three dctaile. 281), reports a case of a piece of hoop-iron removed from a c^'st in the left lung, ojiposite the third rib, where it had remained for fourteen years, the sailor, a man 44 years of age, having been wounded in 1812, and dying from inllurnmation of the lung in 1826. Leash {Catalogue of the Museum of the Royal College of Surgeons) reports the history of Henry liarrott, 1st Life Guards, wounded at Waterloo, June 15th. 1815, in the left thorax ; he lived forty-two years and a hundred and seventeen days. The ball was found iu an abscess containing a pint of pus. In cases in which a blade is impacted in a rib and broken short off, Gerard’s expedient of pushing it out with tlie finger protected hy a thimble, within reach of the forceps, must not bo forgotten. See in the Army Medical Museum, SECT. I, Spec. 961, a wet preparation of lung, with a piece of bone driven into its substance by shot. Case of John W. L , Co. D, 3d Wisconsin, aged 20, wounded at Antictam, September 17tli, 1862; admitted to General Hospital at Frederick, .September 24th; died October 28tli, 1862. 7.S 618 WOUNDS AND IN.TUDTES OF THE CHEST. [Chap. V, of wliicli were fatal. Surgeon J. T. Woods observes, of the chest wounds he treated at Chickamauga: “ I have been astonished at the noii-occuiTence of pleuritis, the wouuds being ragged, injuring twice both thoracic and pulmonary pleurae with spiculae of ribs sometimes thrown inward, to irritate the parts and aid in exciting this result ; but, in these cases, the symptoms of plenritis were both infrequent and mild.” Mr. Erichsen says^ “whenever the pleura is wounded, * * whether the lung be injured or not, pleurisy necessarily sets in.” But Dr. Fraser [op. cit, p. 78) believes that “an inflammatory action in the pleural membrane is sometimes the effect of shot or bullet wound in the chest, but not a usual consequence.” There can be no doubt that the expressions of the special student of this subject depict the true condition of things far more accurately than those of the systematic author. When pleuritis arose after chest wounds, its symptoms and progress were not to be distinguished from those observed in the idiopathic form of the disease. Lymphy exuda- tions took place, adhesions formed between the costal and pulmonic pleurse, and serous effusions often ensued, as will be more fully described in treating of hydrothorax. The plastic exudations on the pleura were found in many fatal cases to be very thick and dense. One of the most remarkable instances of this excessive thickening of the pleura, by inflammatory exudation following mechanical lesion of the lungs, is illustrated by the preparation No. 512, of the surgical series of the Museum, which is imperfectly figured in the accompanying cut (Fig. 303); Case. — Private William B , Co. F, 6th Wisconsin Volunteers, aged 18 years, was wounded in the first battle in whicli his regiment participated, at Gainesville, August ‘28th, 186‘2, the first of the series of engagements included under the title of the Second Battle of Bull Run. He was shot through the right chest, and was left upon the field for several hours, but was finally provided with shelter at a field station of the First Army Corps. There was not much bleeding; but a frequent painful cough, with bloody sputa, and dyspnoea, and anxiety, and a quick small pulse. Occasional stimulants, with small anodynes, and cooling drinks, constituted tlie general treatment, and the local treatment consisted in covering the orifices of the wounds with compresses secured by adhesive strips. On September 2d, he was placed in an ambulance train, and, after a weary journey, over rough roads, of over thirty miles, he was admitted to College Hospital, George- town, September 6th, 1862, according to the memorandum of Acting Assistant Surgeon J. Morris Brown, “with a perforating gunshot wound of the thoracic cavity; the missile entered on the right side, between the first and second ribs, about one and a half inches from the costal cartilages, passed downward and backward, perforated the right lung, and emerged at the angle of the fifth rib, which it comminuted, besides chipping the sixth. There was effusion in the right pleura; sonorous rales; exaggerated breathing; he also spat blood.” The prescription book of the hospital is the only guide to the progress of the case during the six weeks which elapsed before its fatal termina- tion. Death resulted on October 21st, 1862. The necropsy revealed the track of the ball. The wood-cut (Fig. 303) represents a preparation of the right lung and of six ribs of the same side. The lung is collapsed and solidified and the pleura intensely thickened after inflammation, the pleura puhnonalis being about two and a half lines in thickness. There is a corresponding thick- ening of the costal membrane. The specimen was contributed, with a brief note of the case, by Acting Assistant Surgeon G. K. Smith. Similar appearances are shown in specimen 3736, figured on page 588 (Fig. 289),^ and in specimens 2424, 1142, 1315, and 696, of the Army Medical Museum. Intense local pleuritic exudation is displayed in specimen 515, case of 8. B , p. 490. Fig. 303. — Section of the right thorax, showing a perfo- ration by a musket ball through the first intercostal space, and extreme thickening of the pulmonary pleura. Spec. 512, Sect. I, A. M. M. * Erichsen, The Science and Art of Surgery^ 5th ed., London, 1872, Vol.I, p. 436. 2 Assistant Surgeon A. A. Woodliull, U. S. A., cites this preparation as a proof that pneumonia is not “a necessary consequence of gunshot wound of the lung.” There is indeed no evidence that there was local infiammatitm at the time that the ball penetrated the lung substance, and though the exudations on the pleura are exceptionally profuse; yet, at the time of death, the lung tissue was pervious in near proximity to the ball, floating in water, and showing little if any trace of inflammatory engorgement. In immediate juxtaposition with the ball, the lung tis.sue had undergone a cheesy metamorphosis Sect. TV.] COMPTJO/VTTONS OF TN.TTTIITFS OF TTTF, ('TTR8T. 619 The pleuritic exudations sometimes were observed, to }dug the wound, as if to rejiair the injury to the serous membrane, as was observed by Dr. John Thomson^ after Waterloo, and by John Hunter in experiments on animals, from which he deduced that this was the natural process of cure. Traumatic Pneumonia . — Tins is noted as a grave complication in two hundred and eighty-five of the penetrating and seven of the non-penetrating wounds of the chest, and resulted fatally in two hundred and twenty-two of the former and six of the latter group. In an interesting report of 1,562 cases wounded after the battle of Antietam, at Hospital Ho. 5, at Frederick, Surgeon Henry S. Flewit, U. S. V., makes the following observations on wounds of the lung: “Sixteen cases of wounds of the thorax and lungs have been received. The number of eases of undoubted penetration or abrasion of the lungs was fourteen. Temporary recoveries of unmistakable lung wounds have occurred in six cases. The word temporary is used advisedly. The final result of penetration or abrasion of lung tissue is doubtful in every case, and ultimately futal ill most. The temporary recoveries have exceeded the iTroportion of the best foreign military hospitals. This favorable result is undoubtedly due in a great measure to the season of the year and the warmth and dryness of the Maryland autumnal climate. The rapid recurrence of traumatic pneumonia complicated and obscured the physical signs, and the earlier deaths took place before means were provided iov post-mortem examinations. In all the fatal cases in which autopsies have been made, traumatic lesions of the lung tissue were discovered, the original injury, however, masked by the products of excessive inflammation and purulent infiltration; in two instances l)assing rapidly into gangrene. It was remarked that the passage of the ball through and through was more unfavorable than where it remained in the cavity. No instance has been known of a ball lodging on the diaphragm. One such case was diagnosticated by a surgeon, but the bullet was subsequently removed from the centre of the quadratus lumhorum. The treatment pursued in all the cases of lung wound was that of nutrition and stimulation. Hurried respiration was quieted by aconite, and exalted heart action subdued by veratrum viride. The administration of these remedies was seldom required more than a few times. In obviously fatal cases from this as well as other causes euthanasia was sought for and promoted by morphine, administered hypodermically or through the wound where possible. The fatal cases rapidly assumed the chai’acteristic appear- ances of the closing period of rapid consumption, accompanied to the last by clear intelligence and the remarkable buoyancy of spirit which often co-exists with the suppurative disintegration of this vital oi’gan. I have observed no instance of traumatic pneumonia extending to the opposite lung. The conservatism of nature is manifested in the effort at limitation and arrest of inflammation and suppuration, and in the extraordinary success occasionally observed in cases apparently the most hopeless.” Surgeon Hewit accompanies his report with the following abstracts compiled by his assistant. Dr. Cherbonnier : Case. — Corporal Emanuel Fulp, Co. C, 27th Indiana Volunteers, aged 40 years, was wounded at the battle of Antietam, Maryland, September 17th, 18G2, by a minie ball, which entered at the internal angle of the axilla, passed directly through the upper lobe of the left lung near its edge, and emerged at the infra-spinous fossa of the scapula. Acting Assistant Surgeon A. V. Cherbonnier, who reports the case, states; “When first seen by me, October 20th, 1862, he was suffering with some shortness of breath, pain in side, cough, and sputa slightly rusty. He had, as he informed me, spat blood only for a few days after the injury, and that in very small quantities. The wounds presented a healthy appearance, and the discharges were of a healthy color and proper consistency. The wounds were ordered to be kept perfectly clean, and to be dressed regularly twice a day, .simple cerate being used. For the pneumonia that was apparent from the pain, shortness of breath, and sputa, and other physical signs, the patient was put upon Bennett’s plan of treatment and with visible effect each day. On October 2uth, some fragments of bone presented themselves near the point of exit and were removed. October 28th : All the symptoms better. The physical signs of the second stage perceptibly passing away and the lung assuming all the symptoms of mere engorgement. October 30th; Patient sits up and is cheerful; wound suppur.ating kindly; patient continued to improve, in fact, walked about the room. •Thomson (Rep. of Obs. in Mil. Hasp, of Belffium, p.'Jl): “ We saw several cases in which the external wounds having healed during tlio con- tmuance of |>leuril5C inHammation, etc.” 620 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, wlion, on Novonibor 8tli, he Imd a chill, followed hy fever, thished face, and hurried re.spiration. The wounds looked dry and had suppurated hut slightly on that day and the day previous. He continued to grow worse daily and died November 15th. I’ost mortem revealed the left cavity of the chest nearly filled with pijs, which was very feetid, and some serum in the pericardium. The lung was entirely collapsed, gray, and presented the appearance of a putrid mass.” Case. — Private li. W. Hill, Co. K, 8th Louisiana Volunteers, was admitted to Hospital No. 5, Frederick, Maryland, November 23d, 1862, with a gunshot penetrating wound of the chest, received at Antietam, September 17th. A minie ball entered the right lung between the thiril and f)urth ribs, going directly through the body. The case was progressing favorably on adnnssion. He had been very low, and it was supposed for some time after the injury that he would die. When first seen at Frederick he was suffering with some cough — more troublesome at night — expectoration not profuse and catarrhal ; right shoulder depressed and the chest considerably sunken below the point of entrance; the lung was (juite solidified above; broncophony. The wound was still sujtpurating, though slightly. The suppuration had been very profuse, requiring dressing three or four times a day. On November 28th, 1832, he was sent to Richmond, at which time he felt quite able to travel and was in excellent si) irits. Without the occurrence of any unexpected symptom he would recover entirely. Acting Assistant Surgeon A. V. Cherbonnier reports the case. Case. — Private Bernard McGofern, Co. A, C3d New York Volunteers, aged 41 years, by occupation a hempdresser, was wounded at Antietam, September 17th, 1832, and admitted to Hospital No. 5, Frederick, Maryland, on September 24th. This is another case of penetrating wound of the lung. Missile, unknown, but supposed to be a round ball, entered the left side of chest, passing through second and third ribs, making no exit. He spat blood for several days after injury; cough very trouble- some and expectoration very profuse and thick. Treated after Bennett’s plan, nourishing and stimnlating diet, with marked benefit, the symptoms diminishing in intensity each d.ay until his discharge from the hosjtital, December 20th, 1862. At the date of his discharge, he had little or no cough ; muscular development fair; very slight shortness of breath, and the chest but slightly deitressed. His spirits and appetite were excellent, and, as he expressed it, he felt (jiiite well. The lung presented the following characteristics when he left: Vesicular murmur faint, but heard ; bronchial respiration; lung not so resonant as in health. He is not a pensioner. Acting Assistant Surgeon A. V. Cherbonnier reports the case. Case. — Private Charles Eldridge, Co. E, 72d Pennsylvania Volunteers, was wounded at the battle of Antietam, September 17th, 1862, and admitted into Hospital No. 5, Frederick, Maryland, on the 23d. Acting Assistant Surgeon A. V. Cherbonnier states: * * “Acouoidal ball entered at edge of posterior fold of axilla, injuring ulnar nerve (paralysis of fifth finger), penetrating lung, and emerging over middle bone of sternum. This certainly was the most interesting case that came to this hospital for treatment and was considered a hopeless one from the beginning. Patient very much emaciated; habitual cough; purulent sj) uta; matter for days emerging from sternum, sometimes amounting to four ounces a day; air also escajting from wound; left lung doing all the work; exaggerated breathing, and a state of hydro-pneumothorax in right lung; dulness over lower two- thirds; cavernous breathing; lung pushed by fluid against spinal column; was kept constantly propped up in bed, unable to lie down; occasional cupping; attention to bowels and kidney; generous diet; cod-liver oil and brandy. This case gradually and steadily improved. During the course of treatment he committed several excesses in diet, producing dysentery, which, however, readily yielded to treatment. On the 29th of December, he was transferred to Hospital No. 1. He had been walking about the ward two weeks before the transfer. Had applied for his discharge and was considered well able to travel. At the time of transfer right side of chest very much sunken; entire consolidation of lung below wound ; above wound very slight vesicular murmur and symptoms of slow incipient phthisis.” Eldridge was discharged March 6th, 1863, and pensioned February 21st, 1866. Examining Surgeon J. H. Gallagher reports that the volume of the lung is considerably impaired; that he has a constant hacking cough, accompanied by pain, and that deep inspiration causes tearing pain. His disability is rated one-half and permanent. Surgeon J. T. Woods, 99tli Ohio Volunteers, makes the following observations on the treatment of traumatic pneumonia in connection with the perforating chest wounds he reported after the battle of Chickamauga : “ The great danger is pueutnonia, the treatment of which is not only delicate and difficult, but likely to prove unfortunate. No occasion was found for Guthrie’s heroic phlebotomy or for active purgations. No indication for antimony or the impairing the blood’s plasticity presented itself. The only plausible hope for successful treatment lies iu early application of remedies, and in this matter lies an error fraught with fatality. The patients are mingled with others iu crowds, the air is often impure, and this, with dejiressed and circumscribed respiratory power, adds fuel to the difficulty; examinations made are not sufficiently frequent and minute to detect the earliest manifes- tations of the disease while within the control of medication. Anodynes sufficient to allay the intense suffering are dictated both by philosophy and humanity, upon the detection of pneumonia in its early stages. The administration of tincture of veratrum viride sufficient to produce its sedative effect and thus arrest by crushing out the disease at once, has afforded most satisfactory results. The impression is made suddenly at the time selected by the surgeon, and, while it throws a barrier iu the way of the inflammatory process, it leaves no traces of a destructive i)rocess of a permanent constitutional character. Great atteiltiou is required to the diet, which should at first be light and made more nourishing as the progress of diseased action taxes more severely the constitutional energies.” Skct. IV.] COMPLICATIONS OF INJURIES OF THE CHEST. 621 “Pneumonia is an invariahle sequence of wound of a lungf says Mr. Erichsen/ in 1869, “and constitutes one of the great secondary dangers of this injury; tlie inflam- mation that is necessary for the repair of the wound in the organ having frequently a tendency to extend to some distance around the part injured, and not uncommonly to terminate in abscess.” Elis American editor and commentator. Dr. Ashhurst,® is more guarded. “Pneumonia and pleurisy,” he says, “(usually limited to the track of the wound) probably occur in most cases of lung wound, which are not rapidly fatal.” Mr. Erichsen’s statement appears to be founded on general inferences and imperfect observa- tion ; Dr. Ashhurt’s concisely embodies the results of his analysis of the evidence on this point. Neither statement is based, apparently, on personal pathological investigations.^ It is certain that pneumonia, in the ordinary acceptation of the term, is not an invariable sequence of wounds of the lung. It is probable that it is not a frequent sequence. Mr. Erichsen proceeds to say that “traumatic pneumonia resembles in all its symptoms, auscultatory as well as general, the idiopathic form of the disease.” This, again, is erroneous; for in a large number of wounds of the lung, the organ collapses, and a condition unfavorable to hypersemia'* * is induced, and the auscultatory signs are modified. The lung does not play and the ordinary respiratory murmur is not produced. Dr. Eraser [op. cit, p. 69) satisfied himself by experiment and autopsies that pneumonia was of rare occurrence after wounds of the lung. My own observations and dissections confirm me in the belief that his arguments cannot be successfully impugned.^ It is obvious that in many of the reports of penetrating chest wounds in the War of the Debellion, the existence of consecutive pneumonia has been taken for granted. Often there is no mention of the physical signs indicative of its presence, and, frequently, it is apparent that the term is not used in a strict sense; but that pleurisy, thoracic effusions, and almost any agglomera- tion of internal disorders are included under this title. Dr. Macleod [Notes, etc., p. 234) refers to a Russian struck by a musket ball near the right nipple; the ball passed behind the sternum, fracturing it badly, and escaped close to the left nipple: “double pneumonia and jjericarditis followed. The whole contents of the thorax were found implicated in one vast inflammation.” This resembles many of the statements made in our reports. Dr. Macleod admits that he was not present at the autopsy, and his observation is valueless as regards the existence of inflammatory exudations in the lung substance. The truth is that there are so many circumstances to impede the military surgeon in arriving at a correct physical diagnosis, and in completing his observations, that deficiencies may well be excused. He is often in the midst of the noise and confusion of warfare; the wounded man cannot, perhaps, be placed in a convenient posture for auscultation ; the facilities for necroscopic examination are not available. These considerations proportionately enhance the value of exact observations. Dr. Klebs [oqj. cit., p. 83), in his report of the one hundred and twenty-nine autopsies of j)atients dying from the effects of gunshot wounds, at Carlsruhe, in 1870, records * KiacilsEN (J. E.). Set. and Art of Surgery, 5th ed., London, 1869, Vol. I, p. 435. I have italicised the statements to which I particularly demur. ^AsiiUUltST (J., Ju.). The l*rinciples arid Practice of Surgery^ Philadelphia, 1872. *80CIX (Kriegschirurgische Erfahrungen, Leipzig, 1872, 8.74). “ I was astonished to find, at many autopsies, how completely even long-shot channels through the lungs would heal, if no foreign bodies had lodged. I liave no doubf that a wound through the lung tissues may heal i^er primam. 1 can also remember cases of shot wounds, in which the thorax was entirely perforated, wliere I could trace, with the greatest ditliculty, the healed or to-a-narroW'fistula-contracted passage of the missile, while the pleural oavitj* was in a state of complete suppuration.” ^Professor SciiUll ( Wiener Wochenschrift., Jan., 1857) remarks that in shot wounds of the lung, (me of the elements necessary to indime pneumonia, the rough and sudden intlation of air into the delicate lung structure, is wanting, as a wijundcd lung is juirtially, if not altogether, undilatable. regret that 1 have been unable to finish, in season for publication in this place, drawings of microscopical preparations of lung tissue from the vicinity of tracks of punctured and shot wounds, s(dected from the thirty-one post-mortem examinations that I have made, dcmon.strating, in some instances, the non-existence of inflammation in close proximity to the wound. I shall avail of an opportunity of introducing them hereafter. WOUNDS AND INJURIES OF THE CHEST. [CTiai*. V, twenty j)08t-7nortem examinations in cases of shot wounds of the lung, and remarks of case 119: “Dagegen ist es der einzige von mir beobachtete Fall, in welchem sich von dem Schusskanal aus Pneumonie entwickelte.” Of the fifty-one cases of penetrating wounds of the chest observed by Dr. Fraser, or collected in Dr. Matthew’s report, only thirteen were attended by pneumonia. In not one of the nine fatal cases observed by Dr. Fraser, in which the lungs were wounded, did pneumonia supervene. It was pr^jsent in one out of nine fatal cases in which the lung was not wounded, and in two out of twelve cases of recovery. It occurred in seven of the twelve fatal cases, and three of the nine cases of recovery reported by Dr. Matthew.^ Commenting on a series of autopsies of patients dying from wounds of the lung, after the battle of Worth, Dr. SociiF observes: “I was astonished to find at many autopsies how small the reaction was in the immediate vicinity of the injured parts. Generally the lung tissue around the track of the ball is oidy hejiatized to the distance of two or three millimetres. Under such circumstances it is evident, that, if no bleeding occurs, and this may happen frequently by the bruised condition of the wound-canal, such an injury may heal without any serious symptoms.” I might accumulate much more evidence on this point, but I think from these facts we may correctly conclude with Dr. Fraser, that ‘‘pneumonia may be, but is not of necessity, * ** a consequence of lung wound;” that when it occurs ‘‘it can rarely be diagnosed at so early a period after the receipt of the injury as to be useful as a diagnostic sign;” and that traumatic pneumonia differs from the idiopathic form in the absence, in the former, of exudations of plastic lymph in the air-vesicles, and of the spreading tendency of the constitutional affection; and in the rarity of pus formation, unless excited by the detention of foreign bodies. Carditis and Pericarditis . — The comparative immunity from inflammation after injury, that we have observed in the parenchyma of the lung, when contrasted with the effects of wounds of its membrane, is yet more conspicuously displayed in the effects of mechanical lesions upon the heart and its serous envelope. Enough examples of wounds of the heart, in which the fatal issue was sufficiently delayed to afford time for the devel- opment of inflammatory phenomena, have been observed to warrant the conclusion that parenchymatus inflammation of this organ is as infrequently the result of injury as of disease.^ I have examined two cases where patients survived a fortnight or more after shot wounds grazing the heart, in which the pericardium was thickened and the visceral as well as the reflected layer of the pericardium was thickly coated with shaggy exuda- tions; but the muscular structure presented no alterations discernible by the microscope.^ If an analogy might be instituted between the effect of tension on inflamed striated muscle in the trunk or extremities, it would be inferred that the slightest degree of inflammation of the muscular structure of the heart would cause unendurable anguish in its movements * Matthew {op. tit., Vol. II, p. 321) : ‘‘Extensive pneumonia did not appear to be a common occurrence. Pneumonic consolidation was more generally confined to the neighborhood of the injury, or at all events to the lobe implicated, and sometimes, as may be observed in the cases hereafter appended, the wound in the lung healed with hardly a trace of tlie inflammatory process in the substance of the organ.” ^SOCIX, A., Kricgscliirurgische Erfahrungen u. s. w. Leipzig. 1872, S. 75. ^See ROKITANSKI, A Manual of Pathological Anatomy. Translated from tlie German by C. H. Moore. Am. cd., Philadelphia, 1855, Vol. IV, p. 131. ** Compare Rixdfleiscii, A Textbook of Pathological Histology. Translated by \V. C. Kloman, M. D., Philadelphia, 1872, p. 231. “ In the striated muscles of the trunk and the limbs it is conformable to experience that even the slightest degree of inflammation, for example, even that slight tumefac- tion which we find accompanying chronic rheumatism, and (jf which it has not yet been decided whether it essentially goes beyond a considerable degree of hyperaemia, is combined with the severest functional disturbance. The muscle rests in a contracted condition. The slightest attempt to stretch it meets with the most decided resistance from the patient, because of its painfulncss. If we attempt to transfer these experiences to the licart it is readily manifest that even the slightest degree of diffuse inflammation must have, as a consequence, the stoppage of the lieart, and, therefore, the death of the i)atient, and that only subsequent stages of the inflammatory process, would, in general, be j)ossiblein i»artial affections.” Sect. IV.] COMPLICATIONS OF INJUEIES OF THE CHEST. 623 and lead to its stoppage. On the other hand, in all of the cases examined, in whicli halls had wounded the pericardium, or even brushed against it, the physical signs of pericarditis were observed; and the post-mortem examinations revealed extensive exudations and efiusions. The progress of these cases to their fatal termination was usually very rapid. ^ From the solid exudations on the serous membranes, in wounds of the chest, we pass to the consideration of the gaseous and liquid efl’usions within the cavity of the thorax that often attend these injuries. The illustrious John Hunter pointed out this distinction in wounds of the chest compared with wounds of the two other great cavities, — the head and abdomen, — that the parts “are not under the same circumstances that other contained and containing parts are; for in every other case the contained and containing have the same degree of flexibility or proportion in size. The brain and skull have not the same flexibility, but they bear the same proportion in size. From this circumstance the lungs immediately collapse when either wounded themselves or when a wound is made into the chest and not allowed to heal by the first intention, and become by much too small for the cavity of the thorax, which space must be filled either with air or blood, or both ; there- fore adhesion cannot readily take place; but it very often happens that the lungs have previodsly adhered, which will frequently be an advantage.” Pneumothorax . — Air may be effused in the pleural cavity by a laceration of the lung from external contusion, or the rupture of air-vesicles, or of vomicse in forced expiration, or by wound of the lung by a fractured rib, or, lastly and most commonly, by a wound penetrating the thoracic walls. It is generally associated with emphysema; but either condition may exist independently. Where there is an external wound, communicating with the cavity, the air is sucked in on inspiration and is forced out in expiration in an amount corresponding to the extent to which the lung expands. If the wound is small and oblique, or tortuous, the air finds its way among the meshes of connective tissue and emphysema is established. If the wound is large and communicates directly with the cavity, the lung, unless connected with the costal pleura by adhesions, soon collapses, and the space it occupied is filled with air. If there is no disturbance of the equilibrium of pressure of the external air and that admitted to the wounded side, the patient may breathe with comparative comfort with the sound lung; but if air is confined and con- densed in the injured cavity, the sound lung is compressed, and distressing dyspnoea arises. The symptoms of pneumothorax, then, are dyspnoea, varying in degree, exaggerated resonance on percussion, absence of the respiratory murmur, amphoric respiration, if air inflates at all the collapsed lung. The intercostal spaces are effaced, the ribs elevated, and the injured side enlarged, if there is obstruction to the escape of the air. The chief subjective symptom is a sense of constriction at the base of the thorax. It was the general experience during the war that traumatic pneumothorax very rarely assumed such a phase as to excite alarm. In the vast series of cases of chest * 'ITic following* articles, in addition to those cited on p. 534, may be consulted in reference to lesions of the heart and of its sac : COXR, J. K., Sonm observations on Wounds of the Hearty Am. Jour. Med. Sci., Vol. IV, p. 307, (). S., 18:39; Davis, T., Foreign Body in the Heart of a Boy, Am. Jour. Med. Sci., Vol. XV, p. 20.1, O. S., 1834; Wound of the Heart, Am. Jour. MciL Sci., Vol. XXV, p. 22.5, O. S.. 1839; lilClIAUDS, O. W., Case of Wound of the Heart, Boston Med. and Surg. .Join*., Vol. XXXV, p. 330, 1847; TliUGIEN, JOHN W. II., A Case of Wound of the Left Ventricle of the Heart; Pattent survived five days; with remarks, Am. Jour. Med. .Sei., Vol. XX, p. 99, 18-50; HOPKINS, Ji. 0., Gunshot Wound of the Heart; Death two weeks after the Accident, Boston Med. and Surg. Jour., Vol. XLVII, p. 534, 18.53 ; Bai.cii, G. B., A Case of Gunshot Wound ; In which a Leaden Ball remained in the Walls of the Heart for Twenty Fears, Boston .Med. and Surg. Jour., Vol. LXIV, p. 515. 1861 ; BOHEHTS, J. B., A Man runs Sixty Yards aiul lines One Hour after being shot through both Lungs and the Bight Auricle if the. Heart, Hielitnond and Louisville Med. Jour., Vol. XII, p. G07, 1871 ; IkvUAlds, M., Observation de jdaie penetrante de poi trine avee lesion du jJtricarde, in Bee. de M6m. de Med., de Chir. ct de I'harrn., Paris, 1836, T. XL, p. 32.5; TOURNKL, Observation d'une plaie pinHrante de lapoitrine, avec lision du cceur, dapounion ct de la branche idirinigue gauche, in li(X. de Mem. de Med., etc., Paris. 1836, T. XXXIX. p. 174. 624 WOUNDS AND INJURIES OF THE CHEST. [CllAl-. V, wounds, tins complication is noted as troublesome in less than half a dozen. ^ Yet there are many recorded instances^ in which suffocation appeared imminent from the wounding of the mediastinum upon the sound lung. In such cases, it would be proper to dilate the wound, as Boyer, Dupuytren, and Guthrie recommend, or to practice thoracentesis if the wound has entirely closed, guarding against the readmission of air by attaching a pipe or bladder to the canula of the trocar. Saussier^ has collected some valuable observations on this point. Hydrothorax . — Serous effusion into the cavities of the pleura or pericardium is an occasional result of traumatic inflammation, and gives rise to most of the symptoms attending other liquid effusions, as dyspnoea, lividity of countenance, and the other phenomena attendant on imperfect aeration of the blood, with the physical signs of dulness on percussion, varying according to posture, and oegophony. In most cases of liquid effusion in the chest after wounds, the extravasation is more or less sanguinolent or purulent, and hence, in the clinical histories, few cases are reported under this head. AVhen dyspnoea is urgent, jJuracentesis is the principal and reliable remedy.^ Haemothorax. — Sanguineous extravasation within the pleural cavity may result from lesions of the heart or arteries proceeding from it or veins emptying in it, or from wounds of the mammaries and intercostals, or from wounds or lacerations of the sub- stance of the lung. It occurs at the moment of the wound or several days afterward, when the clots obstructing the divided vessels fall. It may rapidly fill the sac or slowly accumulate, varying in extent and rapidity according to the number and size of the vessels wounded. When rapid and profuse the patient perishes promptly from asphyxia, and hence the cause of many deaths 'on the battle-field. When less copious, and grad- ually extravasated, it gives rise to a series of phenomena which awaken the surgeon’s utmost solicitude. Dyspnoea may become excessive ; the breathing is frequent and labored ; there is urgent anxiety and oppression and agitation ; the patient seeks to sit upright (orthopnoea) or can tolerate only a dorsal decubitus, or can rest only on the wounded side, or throws himself from one posture to another, drawing up the thighs, elevating the head and shoulders, in short, fighting for breath. He has a sense of great constriction and weight at the base of the chest. There is dulness on percussion, and the respiratory murmur is absent on the wmunded side to the level of the effusion ; the intercostal spaces are jirotuberant, the ribs are separated and raised, the hypochondriac region is prominent, the injured side moves but little in respiration. These physical signs are modified when air is present in the cavity; then there is tympanitic resonance above, and below absolute dulness. The undulations of the fluid are felt by the patient in sudden movements. The blood gushes out of the wound in coughing or violent expiration. Superadded to these signs are those of copious haemorrhage; the pulse becomes * Abstracts of tlircc of these cases are printed: Beck, jn 493; Lewis, p. 494; Eldridgc, p. 520. Two recovered; the third was attended by emphy- sema and empyema, and the patient succumbed from exhaustion, not from suffocation. 2 BOYEU, Ti'aiti dcs Mai. Chir., T. VII, p. 301 ; DUPUYTREX, Let^ons Orales, T. VI, p. 331 ; Gutiirie, Comm., p. 439. ^ Saussier, Recherches sur la Pneumothorax et les Maladies qui la produiscnt, Paris, 1841, p. 81. iTAitD {Dissertation sur les Collections gazeuses qui se forment dans la Poitrine, Paris, 1801) specially studied this morbid phenomenon. Laexxec {TraiU de V Auscultation mediate et des Maladies des Poumoyis et dii Cceur, Paris, 1831) treats of this subject with characteristic accuracy. Our immeasurable obligations to him and to Auenbrugger {Inventum novum ex Percussione Thoracis humani, Vienna, 1761) are never to be forgotten in considering the diagnosis of affections of the chest. ■* Duverney, Sur V Hydropisic de Poitrine, in Jil^m. de I'Acad. des Sciences de Paris, 1703, p. 174 ; TeiciimaYER, II. F., Diss. de Jlydrope Pectoris, lena, 1727; Morand, Sur une Ilydropisie de Poitrine Guerie par Operation, in Mem. de TAcad. royale de chirurgie, 1759, T. II, p. 545; VOGEL, Diss. de Hydrope pectoris, Gottingen, 1763; Geiiler, Diss. de Jlydrothoracc, Leipzig, 1790; OTTO, Diss. de llydrothorace, Franefort, a. v., 1800; Maclean, L., An Inquiry into the Nature, Causes, and Cure of Ilydrothorax, Sudbury, 1810. ® Consult Lidell on Traumatic Uxmorrhage, New York, 1870. Sect. IV.] COMPLICATIOKS OF INJURIES OF THE CHEST. 625 frequent, small, irregular; tlie face is pallid, tlie lips livid; the extremities cold; vertigo, singing in the ears, and other premonitions of syncope supervene. In the presence of this formidable array of symptoms, the surgeon’s first thought is to stanch the bleeding. If it proceeds from the heart or greater vessels, he can do nothing; but in lesions of the sub- clavians and carotids, and of the innominata even, he will compress, and if the haemorrhage can be temporarily controlled, he should apply ligatures. The mammaries and intercostals will be tied, if possible, and can always be controlled by compression. There remains for consideration only the bleeding from the lung tissue. The application of cold to the chest, the administration of cold acidulated drinks, of opium, of digitalis, and acetate of lead, • perhaps, may be of some utility; but the important point, on which much difference of opinion existed during the war, is whether the wound or wounds shall be kept open or closed. Until a comparatively recent period, no doubt was entertained that the surest mode of arresting the luemorrhage was to take blood from the arm. But, as will be seen farther on, this treatment is practically abandoned by American surgeons, and even those who still rely on venesection in inflammation, discountenance “preventive bleeding,’’ or for hgernorrhage.^ The results of opening the wound and giving free egress to the blood, and of closing it and allowing the blood to accumulate and to arrest the bleeding by its own pressure, regardless of the danger of asphyxia, have been discussed on page 523. Probably this perplexing problem admits of no invariable solution. Chassaignac^ proposed, in these cases, to encourage collapse of the lung, and thus arrest its bleeding, by injecting air into the pleural cavity ; but I do not know that this theoretical suggestion has ever been acted on. Larrey advised that the wound should be closed uniformly. I infer, from personal observation and from the reports, that the most judicious surgeons followed what may be called a mixed plan, which is described by M. Legouest,^ whose excellent practical precepts I have always pleasure in quoting. In the first place, the wound should be closed, and cold, with ice if accessible, applied to the chest, and warm frictions and sinapisms over the extremities. One of two things must happen; Either the haemorrhage ceases, the pulse rises, the warmth of surface is restored, the fearful array of symptoms gradually disappears ; or else the bleeding goes on, and the effects of the effusion are more and more menacing. Then the wound must be reopened, and, if necessary for the evacuation of the blood, enlarged. If the escape of blood does not relieve the patient, but only weakens him, then the wound must be closed again, the revulsive applications to the general surface and the refrigerant local applications resumed; the patient laid on his injured side, his head and shoulders raised, his chest bandaged, if he can tolerate it, and thus persevering, opening and closing the wound, hoping to gain time, and to stave off the most pressing danger. When the immediate peril is passed, the efiusion is to be dealt with, and this may be considered in treating of empyema. Though Hennen’s observation, that where the third day has been safely got over great hopes may be held out, is true and very apposite in this connection, yet many examples of intermediary and secondary internal hemorrhages were observed during the war, and the surgeon should be on his guard against such contingencies, especially when the position of the wound favors the supposition that an intercostal or internal mammary artery may have been wounded. The abstracts detailed * Leoouest, Chirurgie d'Armic, ed. 1872, p. 353. In this juncture, the majority still advise liberally repeated bleedings, saj’S M. Legouest; but : “iVous repoussons energiquement les saignees, comine 6taDt plus nuisiblo qu’utile.” ^ Chassaionac, Thfise, 1835, p. 82. ^ Legouest, Chirurgie d' Armce, p. 353. 79 626 WOUNDS AND INJURIES OF THE CHEST, [Chap. V, in this chapter, include twenty-one cases of hsemothorax, and among them are several in which the internal bleeding took place in the third week, and one, described on page 493, had fatal bleeding as late as the thirty-sixth day. Dr. Stromeyer^ cites similar examples. John Hunter’s® admirable account of hsemothorax is quoted by Mr. Poland in his article in Holmes’s System, which is issued to medical officers. Dr. Chisolm,^ in his excellent Manual, gives a graphic account of a case of primary hsemothorax, in which the extrava- sated blood was evacuated by partial inversion of the body. When hoemothorax attends a shot perforation opening on the posterior part of the chest, the blood is likely to gain admission to the muscular interstices and to dissect its way downward, producing the lumbar ecchymosis so much commented on as a sign of penetrating wounds of the pleura. Hennen {op. cit, p. 397) has observed this phenomenon as a sequence of wounds of the infrascapular vessels. On pages 575 and 576, I have given at length the views of Valentin and Larrey on this subject. Surgeons are now gen- erally agreed that lumbar ecchymosis is of secondary importance as a sign of hsemothorax.^ The blood effused in the pleural cavity rapidly coagulates in the costo-diaphragmatic angle and lower part of the chest; and here it is that the cautions in regard to rash explorations of penetrating chest wounds, on which surgical teachers justly insist, are especially applicable; for a premature disturbance of the caillot tutelaire may reopen the mouths of the bleeding vessels. The presence of the blood commonly provokes an unwonted serous effusion in the pleura. A limited effusion may be absorbed, even when pneumothorax coexists. When the effusion is profuse, the blood is not absorbed, and a part remains liquid, with diffluent coagula floating in it. This liquid soon undergoes a purulent or putrid decomposition, which is indicated by a febrile reaction, with evening exacerbations, a dry and dusky skin, and frequently by oedema of the lower limbs. The blood is usually unconfined in the pleural cavity, but it may be encysted by plastic exudations. Where it thus becomes circumscribed, it may be partially absorbed, or may give rise to an abscess, which, through a fortunate conjunction of circumstances, may make its exit externally or be discharged through the bronchial tubes. Empyema . — Traumatic serous and bloody effusions in the chest, if not absorbed, decompose, and by the irritation they induce lead to the formation of pus. The same result is engendered by the presence of foreign bodies, and by necrosis of the bony case of the thorax. Empyema is, therefore, a somewhat frequent secondary complication of wounds of the chest. It is a subject that has been so fully illustrated by examples in the * Stromeyer, li. {Erfahrungen uher Schusswunden ixn Jahre 1866, Hannover, 1867, S. 42): “Twice did it happen, that men, who had been con- sidered cured, were allowed to go about, and then died from internal bleeding of the injured intercostal artery. The death of the one followed on the thirty-fifth, and of the other on the fiftieth day.” 2 Hunter. IForA-s hy Palmer^ Vol. Ill, p. 567, and A TrtaiUt on tliK Bloody Injlammation, and Gunsliot Wounds ; by the late JOHN HUNTER, London, 1794, p. 553. * Dr. Chisolm observes (A Manual of Military Surgery, 1864, p. 325) : “The effect of this escape of blood from the cavity of the chest was exemplified in the case of Major Wheat, who was shot through the chest at the first battle of Manassas, the ball entering in at one arm-pit and escaping from the other on a level with the nipple. Soon haemorrhage caused great oppression and, finally, fainting. When he partially recovered his conscious- ness he found himself surrounded by his men, who, believing him dead, had stripped his body of every vestige of rank, so as to prevent recognition by the enemy. One of his men (a powerful sergeant), determined to save the body from indignities, had seized the major’s arms at the wrists, and, with the assistance of a comrade, had slung the body over his back, drawing the arms of the supposed dead man over each shoulder, and in this position started off from the battle-field. Major Wheat was himself a powerful man, and his weight, in addition to his chest being drawn forcibly against the broad back of his sergeant, so increased the pressure upon his lungs as nearly to extinguish the flickering spark of remaining life, when he suddenly felt a gush of blood and air from both arm-pits, followed by such immediate relief that he found his breath returning, and when he reached the ambulance wagon he could stand up. Arriving at the hospital, he found that he had so far recovered, under this rough treatment, that he could walk with assist- ance. Quiet, with but little medication, soon completed the cure, and, in course of time, enabled the major to resume his command.” ^ Sanson, Des Ilimorrhagies traumatiques, Paris, 1^36, p. 260 ; Louis, Mem. de V Acad, de Chirurgie, T. IV, p. 24 ; Legouest {op. cit., p. p. 358) ; Erichsen (op. cit.), Vol. I, p, 434; Dr. Macleod (op. cit., p. 2.39) says it appears seldom. Dr. Ashhurst (op. cit., p. 360) places it among the more trustworthy physical signs of hiemothorax; but on the authority of Valentin and Larrey. Callisen, Desgranges, and Chaussier give instances in which it was present without hmmothorax existing and absent where there was efl'usion of blood in the pleural cavity. Sect. IV.] COMPLICATIONS OF INJURIES OF THE CHEST. 627 preceding pages, and discussed in all its varieties by autliors,^ that it is only necessary here to advert to its comparative frequency, and to the sources of information in regard to its treatment. In the subsection on thoracentesis, the practice of making free incisions for the evacuation of putrid or purulent effusions, as preferable, in traumatic cases, to paracentesis simply, and the use that was made during the war of drainage-tubes, injections, canulas, etc., has been described. I omitted, however, to record a plan of treatment proposed by Assistant Surgeon A. H. Smith, wishing to ascertain if it had been tested experimentally. As far as I can learn, it has not been used practically by the inventor or by others: In a letter to the Surgeon General, dated Hospital No. 13, Nashville, Tennessee, May 20th, 1863, Assistant Surgeon A. H. Smith, LT. S. A., transmitted a mechanical contrivance designed for use in the treatment of penetrating wounds of the chest not involving the lung to such an extent as to cause danger from hmmorrhage, and having for its object the prevention of the entrance of air into the pleural cavity through the wound, while at the same time the air and other matters within the cavity are to be permitted to escape. The appliance, figured in the adjoining cut (Fig. 301), is thus commented upon by the writer: It is merely a valve to be applied to the chest over the wound, permitting the air, blood, etc., to pass out, but preventing the passage of air inward. The whole instrument is to be immersed in water, and when perfectly saturated api)lied to the chest, the centre corresponding to the wound. It is to be retained in ])osition by a bandage wound around the body, having a hole in it for the piece of intestine, forming the valve, to pass through. By keeping the instrument con- stantly wet the leather will remain closely applied to the skin, while the proper action of the valve will, at the same time, be secured. If there be two openings in the chest, the valve is applied to the most dej>endent one, the other being closed. Even in a case in which the lung is already collapsed, I think the motion of the chest would, so to speak, pump out the air in the pleura, and, unless the lung be wounded in such a way as to open a free communication between the bronchial tubes and the pleural cavity, it must eventually expand again to its normal dimensions. And even if air entered the pleura through the lung as rapidly as it was pumped out through the external wound, there would still be a certain amount ‘ Fig. 304. — Dr. A. II. Smith’s apparatus for effusiuns of circulation of air through the lung, which might in the end be of great advantage to the patient. On trial, it may be found best to cover the inner side of the leather Sect. I, A. M. M. with some adhesive material, and keep only the intestine wet. If found to answer the purpose, I would propose to have a number of these valves in each hospital knapsack, for use on the field.” Thoracentesis, and the other measures employed in empyema, have been discussed on page 573 et. seq. 'Fabricius, De empyematis vafura et curatione, Rostock, 1626; Marquaut Schlegel, Dissertatio de empycmate, Jena, 1639; liALDUS, Dis- sertatio de empyemate, Leyden, 1646; CRAMEFER,’ Dissertatio de empyemate, Leyden, 1647; Wedel, G. W., Dissertatio de empyemate, Jena, 1686; ECKIIOCT, J. vox, Dissertatio de empyemate, Leyden, 1709; BOXETUS, Sepulchretum Anatomia Practica, T. Ill, p. 348, Geneva, 1700; INGRAM, Practical Cases and Ohs. in Surgery, London, 1751; FURSTENAU, In Ephem. nat. curios., Vol. IX, p. 329, 01)s. 78, 1752; WARNER, Philosophical Transactions, Vol. XL, p. I; Herrissant, An in empyemate necessaria licet raro prospera paracentesis ? Paris, 1762; A. MONRO, State of the Facts concerning the first Proposal of performing the Paracentesis of the Thorax, Edinb., 1770 ; Marciiettis, Sylloge Observat. Medico-chirurg. rar. ohs. 43, pp. 99, 102, 104, Naples, 1772; BROMFIELD, Surg. Ohs. and Cases, Vol. I, p, 24, 1773; NICOLAI, De utilitale et necessitate paracenteseos thoracis, Jenae, 1775; Hemmanx, Med. chir. Aufsdtze, Berlin, 1788; Flajani, Collez. d'osservaz., Roma., 1802, oss. 47, p. 145; GUMPRECllT, De pulmzmum ahscessu aperiendo, Gottingen, 1796; Zang, Darstellung hluliger heilkunstlerischer Operationen, Wien, 1821, Band III, Tb. I, S. 132; Peli.f.tan, Mem. sur les ipanchemens dans la poitrine et I’operation de Vempyime, in Clin. Chir., T. III. p. 236, Paris, 1810; Albrecht, De paracenie.si pectoris, Berolini, 1816; Jackson, S., Case of Effusion into the Chest, in which Paracentesis was performed, Phil. Jour, of Med. and 1‘hys. .Sci., 182.5, Vol. X, p. 119; FaURE, Observation sur la ponction de la jmitrine, pratique pour remedier aux divers cas d'epanchement pleuritique, Gaz. Jled. de I’aris, 1836, p. 759 ; SedillOT, Ch., De Voperation de I’cmpyeme, Th2se do Concours pour la Chair de JI6d. opferatoire, Paris, 1841 ; Roe, Hamilton, On Paracentesis Thoracis as a Curative Measure in Empyema, etc., in Lond. med.-ch. Transact., 1844, T. XXVII, p. 198; TROUSSEAU, Pleuresie, Paracentesc de la poitrine, in Clin. med. de V Hotel- Dieu, 1861, T. I, p. 619; HITCHCOCK, A., Paracentesis Thoracis, Four times performed on the same Person, 37 lbs. 7 oz. of Fluid Discharged, Partial Recovery, Boston Med. and Surg. Jour., Vol. .50, 1854, p. 69; SllATTUCK, Empyema, Paracentesis, Spontaneous Opening, Death, Boston Med. and Surg. Jour., Vol. 53, 1856, pp. 80 and 81; BOWDITCII, IL, On Paracentesis Thoracis, Boston Mod. and Surg. J■ JlpBSiMi>,i^.vA^ ■' " (>: !■, ; i. >.'. a ,1 ‘''' ^ , . 1 •* ■-■»'•*,' m/^ wi* id. i ii r *’ r ' ; ^ . *|r,|# ^■'., '■■•V, ■ ;V^(^.^Vv ''f'.i*'’ '‘l»(||| ■■ .■ 1>4 , "■^ " i ' ‘ ■ :iV . '. ■ ' ' - ■■ ‘ ' t ■ 1 ^' A' •c.r. ,vVt ■•, '' - n fl^;' ' i|J?- .' (• >i ifii' 'i '.'* *' ■/I •. ' - 4 ■ ** .v^ 1 .^ ■*. ’ " ’• Jt ‘ lafe * '■<■' * -!<< * **,/.•, -,' nkgrU*- ♦.»’V.■ ' . / 1 *, - I ■ >'■:. -> •;i. ; ., . /,t - 4 -■• ' 1 »' 'k,. “,■ ‘ ,4 ,*• ..• «JW* -V .»»i .^v-<>. ,, , ^ 'V ‘ ’ i''. * -r tf • • ' • I ■ k ■ ‘ '"V: ri- .» V/ • **a ■ >■'. -, - f ^y. is ■ ' fi. r Ik. IF^t -i** k kf. 'I iiM «>/«<•/■' ■ » • . -•if^ -T- 1 ... . 1 , Vfk. ■ .^. »C-tV'< """ ♦ ' *». -•• .^1,1 ,v u. 1 >,■ r>r .« , ,^i-, . .n. ■« ^ 1 .j j ; Jf* I' **■*.'» t,Sii -Hi ' f — ' '«•'«(♦ .>/%,^fji yr 7 % i,,; 5 -.- -K t , tG- A ^.'■|.^ 'ri ■ r^-. 'as irf‘. ■ ■■V ' .- .’MB ■ ‘ - ■' ■♦ ■ *yA > •>. ' .-I -(?■ '^..- :C- >#" i ’ i'' ' r •• Sect. IV.] COMPLICATIO]S"S OF INJURIES OF THE CHEST. 629 circulation by a short route. In twelve hundred fatal cases of penetrating chest wounds with fracture, pysemia is noted as the cause of death in forty-nine, and some of these cases were attended by metastatic deposits in the lungs. The information contiibuted on this subject will be fully considered hereafter, in the discussion of thrombosis and embolism in 1 By far the larger number of cases of intrathoracic abscesses reported were due to the presence of foreign bodies. Examples have been given of the discharge of such abscesses into the bronchial tubes, with the expulsion of the extraneous substances in coughing,^ and cases also in which the foreign bodies either gained admission to the oesophagus, or passed through the diaphragm and entered the alimentary .canal lower down and were voided at stool.^ More commonly, these abscesses discharged through the thoracic walls. Phthisical Tendencies .' — Among the remote effects of wounds of the chest are violent inflammatory affections, ever subject to relapse, tedious exfoliations and suppura- tions, and a diseased condition which, as Hennen says, though it cannot be strictly called pulmonary consumption, agrees with it in many points, particularly in cough, emaciation, debility, and hectic. The pension examiners frequently report such cases as “ consumption,” and record the fatal event as due to phthisis. Invalids that have been wounded in the lung are almost invariably readily affected by atmospheric changes. Yet it has been claimed that a diseased state of the lungs has been ameliorated or even cured by a pene- trating wound. Desgenettes^ communicated a case of the sort to Larrey, and the latter® mentions a case of an ofiicer with “well characterized phthisis,” and in like manner Usher Parsons® entertained a similar belief, and Hennen,’’’ though he never observed such an example himself, was reluctant to discredit the testimony on the subject. Hone of the cases or autopsies reported since the war appear to establish any relation for good or evil between wounds of the chest and true tubercular phthisis.® * Consult ViKCHOW, Die Cellular-Pathologie in Hirer Begriindung auf physiologische und pathologische Gewehelelire^ Vierte Auflagc, Berlin, 1871, S. 234 ; Bokitaxski, Lehrhuch der Pathologischen Anatomie, Wien, 1861, Dritter Band, S. 76. * See case of Colonel Collis, p. 584, and the less authenticated case of Miltenberger, p. 596. Dr. A. J. C. Skeexe {Med. and Snrg. Reporter, I'hila., 1862, 'N'ol. IX, p. 160) reports the case of Sergeant Allen R. Foote, Co. B, 3d Michigan Volunteers, as having received a penetrating -wound of the right lung, and expectorating pieces of the ball eleven weeks after the injurj^. This circumstance is not noted in the reports of the Chesapeake and Long Island hospitals, but the patient is recorded in the latter as returned to duty October 1st, 18G2. The sergeant -w’as promoted to a lieutenancy in the 21st Michigau Volunteers, March 3d, 1864, and mustered out June 8th, 1865. A fourth* •* case is printed in the Boston Medical and Surgical Journal, 1668, Vol. I, N. S., p. 339, of Private A. N. Rossiter, 49th ^Massachusetts Volunteers, said to have been wounded at Port Hudson, March 14t!i, 1863, and sufFering subsequently from haemoptysis, and coughing up, five years afterward, a flattened buckshot, after which ‘“he was wholly relieved from his disagreeable symjdoms.” He is not a pensioner, and the h(»spital record gives the diagnosis “chronic diarrhoea,” without indication of any wound. 3 See cases of Stolpe, p. 515, and of Belt, p. 584. •* Desoeneitks told Larrey that in the painting of the death of General Wolfe, by Benjamin West, the figure supporting the fallen hero in its arms is the portrait of an otDccr who received a ball in his chest and was thus cured of well-marked ]>hthisis. ® Larrey {Memoires de Chirurgie Militaire et Campagnes, 1812, T. HI, p. 37()), on relating this statement of Desgenettes, records two examples of recovery from phthisis, following amputation <.f the shoulder-joint, as “proofs oi the salutary etfects of certain perturbing causes on the most hopeless diseases, and an explanation of phenomena that have astonished the greatest observers.” One is the case of Lieutenant Colonel Hoevemeur, of the 2d Dutch Lancers, the other of a private lancer of the Guard, in whom the symptoms of pulmonary phthisis and those of the scrofulous cachexy, developed in the highest degree, entirely disappeared.” ® PARSONS. AYia England Journal of Medicine and Surgery, 1818, p. 209. ^ IlEXNEX {Principles of Military Surgery, 3d ed., 18‘29, p. 400) : “ An instance of this kind has never come under my notice; although I have very resiiectable living authority to say that a strong predisposition to phthisis was suspended in one case and spasmodic asthma remarkably relieved in amjther, by penetrating wounds of the thorax.” ® I think the doctrine of the cure of pulmonary consumption through the agency cf penetrating wounds of .the chest should be regarded as a fable, perpetuated by respectful comidiance with authority. It is said (T rhalems, by Pliny {Naturx llistoriarum, Lib. VII, Cap. /, p. 16(i^, deploratus d medicis vomiae morho, the abcess was opened by a sword thrust, and the patient -was cured. Guthrie has grouped Phalerus, on what authority he does not state, with Jason and Prometheus, and says that being expected to die of abscesses of the lungs, they went into battle for the j)urprinted in tlte seventh volume (d tlie New England Journal of Medicine and Surgery, 1818, page 269. In relating the case of Captain Charles Gordon, wounded through the chest in a duel, Dr. Parsons says that he had been “subject to cough, and was threatened with a pulmonary allcction, all whicli the bleeding from the wound appeared to remove. A similar instance is related to me by Dr. Wheaton, of Providence, in a case where a musket ball passed through the right lung of a young man laboring under phthisis pulinonalis. The hjenioiThage was very profuse, but was followed by a speedy recovery both from the wuunatient was not more than 17 or 18 years of age.” * * Sect. IV.] COMPLICATIONS OF INJURIES OF THE CHEST. 633 Contraction of the^ Chest . — A deformation of the thoracic walls is one of the remote results of severe injuries of the thorax. After the absorption or evacuation of extensive pleuritic effusions, if the lung remains unexpanded, the side of the chest falls in to accom- modate itself to the crippled lung, and there is a corresponding incurvation of the spinal column. This flattening and deformity is noted as extensive in about twenty-five cases of pensioners who recovered after large extravasations in the pleural cavity. More limited depressions are observed in a number of pensioners who have suffered from necrosis and loss of substance of the ribs, and thoracic flstulie.^ Mechanical apparatus have not been found of utility in these cases. In a few instances, with the partial resumption of its functions by the lung, the deformity of the chest has been in a great measure removed. It was in cases of this class that Bromfield*^ advised the use of wind instruments and pneumatic apparatus to promote the inflation of the injured lung, propositions which John Bell ridiculed in his lively style. Secondary Emphysema and Pneumothorax. — These affections occurred in rare instances as secondary complications, very obscure and perplexing in their symptoms and progress. A veteran at the Soldier’s Home, whose left arm had been disarticulated at the shoulder, received a blow from the fist, or from a blunt weapon, over the right nipple. Surgeon Laub found no fracture of the ribs; but there was an unnatural resonance on percussion, cough, and a purulent expectoration, and, after a few days, a crackling tumor appeared and spread over the great part of the pectoral muscle. After a few weeks there was evidently a communication between this tumor and the pleural cavity, and metallic tinkling and the signs on percussion, indicated the presence of air and of pus in that cavity. The arm became swollen and emphysematous, and pus pointed below the insertion of the coraco-brachialis, and, notwithstanding a free incision here, dissected its way down the forearm. Soon after, there was profuse hajmorrhage from the incision of the abscess, and a tourniquet was made to compress the brachial artery. The haemorrhage recurring whenever pressure was removed, and the entire arm and forearm being infiltrated with ■ pus and air, the bleeding point was exposed by a very free incision along the inner border of the biceps, and ligatures were placed above and below upon the bleeding vessel, which was the collateralis magna, enlarged to nearly the size of the brachial. The incision was then extended upward through the skin and fascia nearly into the axilla, and down the forearm to the annular ligament. Pus and gas w^ere freely discharged. The immense wound, in a few days, assumed a healthy appearance, the ligatures came away in a fortnight, and the arm recovered without much stiffness. Meanwhile the tumor in the pectoral region subsided, and cough and purulent expectoration gradually disappeared, the normal respiratory murmur was restored, and in a few months, under a sustaining regimen, with cod-liver oil, porter, and other restoratives, the man regained his accustomed health. Hennen details a curious case of secondary emphysema at page 385 of his masterly treatise, and one of the cases which Guthrie observed after Waterloo, which was called a hernia of the lung, would appear, from the brief description, to have presented rather the characters of secondary emphysema. In the latter part of the last century and at the commencement of the present, when the researches of j)hysicists on pneumatics were exciting great popular interest, in cases of secondary pneumothorax, surgeons paid great * Professor GROSS remarks (A St/stem of Surffery, 1862, Vol. II, p. 449), of fistulous thoracic ahbcesscs : “The cure of these afiections, which is generally followed by a remarkable retrocession of the walls of the chest, is sometimes j>rornoted b}' weak astringent and detergent injections.” Chirurgical Observations and Cases, Loudon, 1773, Vol. II, p. 93; John Bkll, Discourses on ^'ounds, Part II, i>. 19. cSO 634 WOUNDS AND INJUEIES OF THE CHEST, [Chap. V, attention to the removal of the air by suction, and various adaptations of the air-pump were proposed for this object. Abernethy treats of this su])ject with his accustomed acumen, in the second volume of his Surgical Observations (p. 171). Wounds of the CEsophagus, Thoracic Duct, Nerves, and Diaphragm. — On wounds of the pectoral portion of the gullet, of the chyliferous duct, of the par vagum, and other contents of the posterior mediastinum, little information was acquired by any of the obser- vations made during the war. Benjamin BelB has given a learned description of the symptoms that should attend lesions of the canal of Pecquet and its tributary lymphatics ; but it is drawn partly from Mangetus, and more largely from the imagination. Of wounds of the nerves our information was greatly extended by the careful investigations of Drs. Mitchell, Keen, and Morehouse ; but, with the exception of lesions implicating the axillary plexus, their researches embraced few cases attended by wounds of the chest. On wounds of the diaphragm much interesting matter was contributed, which must be reserved for consideration under the head of wounds and injuries of the abdomen. Wounds of Doth Lungs. — I have adduced, at page 497 et seq., a number of examples of recovery after shot wounds of both lungs, and have, perhaps, done injustice to the reporters, in expressing great skepticism as to the accuracy of diagnosis in such instances. I am not ignorant that Hemmann, Schlichting, Ravaton, Van Swieten, Forestus, and Schmucker,^ give many examples of both sides of the chest being opened without the accident proving fatal; but I know of no modern instance in which the cicatrix of a ball has been traced through the substance of both lungs at a remote period from the reception of the injury. Erysipelas and Gangrene. — These complications were very rare in the chest wounds treated, except in a few overcrowded hospitals, where almost every solution of continuity became the seat of unhealthy action. In the eight thousand seven hundred and fifteen cases of penetrating wounds of the chest, erysipelas is noted in seventeen cases, of which nine proved fatal; and gangrene in sixty-eight cases, with fifty deaths. In the eleven thousand eight hundred and ninety-two non-penetrating injuries of the chest, erysipelas supervened in one fatal case, and gangrene in twenty-six cases, of which eleven terminated fatally (see page 472). Thus it appears that these complications, though rare, were very fatal. The three following abstracts are gleaned from the scanty notes of cases of gangrene in wounds of the chest reported in detail : Case. — Corporal Charles H. Freas, Co. H, 84th Pennsylvania Volunteers, was wounded in the left side, at Chancellors- ville, Virginia, May 3d, 18G3, by aconoidal hall. He was conveyed by hospital steamer State of Maine to Annapolis, Maryland, where he was admitted to the 1st Division Hospital on May 17th. The missile entered immediately under the head of clavicle, passed through and emerged at superior angle of scapula. On May 21st, gangrene set in at orifice of exit, and on May 22d the wound was two inches in diameter and covered with a thin layer of slough; on June 27th, slight signs of granulations appeared and from this time he rapidly improved, and on July 15th was nearly well. The treatment consisted of administration of stimulants and application of solution of creosote and vinegar, and nitric acid around the edges of the wound. In October he was transferred to I’hiladelphia, admitted to Satterleo Hospital October 27th, and returned to duty May 3d, 18C4. He was discharged the service August 25th, 1865. The case is reported by Acting Assistant Surgeon L. Smith. Pension Examiner E. S. Siinington, Philadelphia, reports, February 13th, 1867 : “ Gunshot wound of left shoulder, causing contraction of muscles ; he is unable to raise his arm to use it. Disability one-half and probably permanent.” Case. — Private Reuben V. Hilands, Co. C, 105th Ohio Volunteers, aged 41 years, received a gunshot penetrating wound of lung at Perry ville, Kentucky, October 8th, 1862. He was treated in hospital at Perry ville during the same month, and, on January 14th, 1863, was admitted to hospital at Camp Chase, Ohio, where he was discharged on that date. The ball passed ' Beli-, B. Of Wound$ of the Thorax, Chapter III, of the 7th edition of his System of Surgery, Edinburgh, 1801. ^IlEMMAN'X, Med.-chir. Aiifsatze. Berlin, 1778; .ScilLlcirriNG, Traiimatnlogia nova antiqun, Amsterdam, 1748 ; IlAVATlON, Chirurgie d'Armee, ou I'raite des Jdaies d'armes d feu and Pratique Moderne de la Chirurgie, Paris, 1770; Van .Swieten, Commentaria in llcrmanni Poerhaave Aphorismus, Paris, 1755; FOUESTUs, Observationum Chirurgicarum Op. Omn., Francof., 1010; ScilMUCKEIt, Chirurgische Wahrnehmungen, Berlin. 1774. Skct. IV.] DIAGNOSIS AND PKOGNOSIS. 635 tliroiigh tlie k'fl scapula and upper portion of lung, emerged at the base of neck and reentered, immediately passing back of trachea, and, removing three upper molar teeth on the right side, came out in front of the lower point of the ear. The apparently erratic course of the bullet may be accounted foi' by the position of soldier when wounded. He was retreating, and stooped with his head turned to the left looking at his gun, which he was loading when struck. Blood issued from the wound of the neck at every expiration, and he could not breathe without great difficulty, except when the w'ound in neck wms closed. March Cth, 186C, Pension Examining Surgeon C. Byles, who reports the case, states that the left lung is dull on percussion and silent on auscultation; the wound in neck occasioned the total loss of his voice, wdiich was recently instantaneously restored by an attack of vomiting; his nervous system suflers much, whole left side weak and paralyzed. Pension Examiner J. P. Hosack, of Mercer, Pennsylvania, reports, January 18th, 1870, that the weakness of lung, shortness of breath, stiffness of shoulder, weakness of arm, and painful aphonia, is equivalent to total disability. Case. — Piivate John IF. Ellins, Co. G, 12th Louisiana Regiment, aged 19 years, was wounded at Nashville, Tennessee, December 15th, 18C4, by a conoidal ball, which penetrated the right lung. He was received into Cumberland Hospital, Nashville, on December 17th, and thence transferred to Hospital No. 1, Nashville, on January 4th, 18G5. The wound became gangrenous, and he died March 10th, 1865. Gangrene of the walls of the track of a musket hall tliniugh the lower lobe of right lung is observed in Specimen 3348 of the Surgical Section of the Museum.^ Tetanus. — The rarity of tetanus as a complication of chest wounds, an observation for which we are indebted to Dr. Fraser,^ is undeniable, and is interesting in connection with diagnosis, as indicating the lesser implication of the sympathetic nervous system in lung wounds, than in wounds of the abdominal cavity. There were seventeen instances of tetanus among the eight thousand seven hundred and fifteen cases of penetrating wounds of the chest. Diagnosis and Prognosis. — Dr. John Jones, ^ our Revolutionary authority in military surger}^, said, “penetrating wounds of the thorax are in general pretty easily distinguished from the peculiar symptoms that attend them. The most remarkable of these is the passage of the air through the wound in respiration and the expectoration of frothy blood from the lungs when they are wounded.” To these accepted signs, emphysema, dyspnoea, nervous anxiety, collapse of the lung, and, later, pleurisy and pneumonia are commonly added by modern authors. A cursory examination will show that none of these symptoms singly merits implicit reliance, though their concurrence affords strong presumptive proof of wound of the lung. Tromatopnoea. — The passage of air through the external wound was once regarded as conclusive evidence of wound of the lung.^ This is disproved by observation and ■experiment. Air will pass freely in and out through a small opening in the pleural cavity ^ Spec. 3348, Sect. I, A. M. M. “A preparation of the lower portion of the right lung, perforated by a conoidal ball which entered between the sixth and seventh ribs, and is gangrenous. Corporal J. P , Co. A, 69th Ohio, Petersburg, 2Gth June. Admitted to hospital at Alexandria, July 4th ; died July 12th, 1864.” 2 Traser. Treatise upon Penetrating Wounds of the Chest, p. 20. The proportion of cases of tetanus given in the text, one in five hundred and twelve cases, does not appear very small. But there W’ere only six cases of tetanus among those wounded superficially in the chest. The comparison should therefore be instituted between the twenty-three cases of tetanus and the total of twenty thousand six hundred and seven chest wounds, or one in eight hundred and ninety-six cases. In I*aris,in 1830, out of three hundred and ninety gunshot wounds, there was but a single case of tetanus, but that one occurred in a penetrating wound of the chest (ISIeniere). The reports of the Indian Mutiny refer to one case of tetanus in the small series of chest wounds CNVilliamson). Of twenty-nine cases of tetanus in the Crimea, but one supervened in chest wounds, a case of trismus in a Prench soldier (Fraser). Larrey does not mention a case. In the Danish "NVar of 1849-50, in nine hundred and twelve wounded, no case of tetanus occurred (Schytz). Sir Gilbert Blane {Observations on the Diseases of Seamen, 3d ed., London, 1799, p. 55.5) states that in a naval action. In April, 1752, of eighty-eight wounded, sixteen had tetanus. Dr. B. Bkck {Allgemeine Militdr-drztliche Zeitung, No. 37, Sept. 15th, 1872) says that among 7,182 wounded of the Fourteenth Corps (Bavarians under General Werder), tetanus occurred in only forty-five cases. ^ Plain, Concise, Practical Itemarhs, on the Treatment of Wounds and Fractures; To which is added an appendix on Camp and Military Hospitals ; Princijtally designed for the Use of Young Military and Naval Surgeons in North America ; By JOHN JONES, M. D., Professor of Surgery in King’s College, New York ; Philadelphia, Third Street ; printed and sold by Robert Bell. 8vo. 1776. ^ Hence, the ‘‘waste of time and wax-tapers in ascertaining the exit of air through the passage ” to which Hennen {3d ed. p. 375) alludes. Dr. ,7. Thom.son remarks {Report of Observations made in the British Military Hospitals in Belgium after the Battle of Waterloo, Fdinburgh, 1816, p. 80) that “it is often difficult to say, in wounds of the chest, whether they penetrate into the sacs of the pleura ; but all doubts with regard to this point aro removed the moment we obscr^'c air coming out of the wound upon coughing.” Of nine fatal cases reported by Dr. Fraser {op. cit. p. b’6) of pencti’ating chest wounds in which the lungs were wounded, this symptom was present in two; of seven fatal cases in which the lung was not wounded, it was present in one; in twelve cases of recovery it wa.s present in one. It was present in two out of twelve fatal cases, in the British Director Goncral’s reports, and in one of nine eases of recovery. Dr. Williamson {op. cit. p. 80) mentions that “twelve perforating gunshot wounds of the chest arrived from India;” * * in four instances, if is mentioned that air passed out of the wounds in the chest. * * “In all these cases, there can be but little doubt of the lung having been wounded.” 636 WOUNDS AND INJURIES OF THE CHEST. [Chap. V, when the lung is uninjured. It may gurgle in a deep oblique emphysematous wound in the soft parts, or in wounds penetrating the anterior mediastinum and pericardium, and not communicating with the pleural cavity. When there is a large penetrating wound of the pleural cavity and the lung is really wounded, tromatopnoea ceases, except in coughing and sneezing, for the simple physical reason that there is no confined body of air subjected to the alternate movements of the thorax (Fraser). Tromatopnoea was not a frequent symptom. It is noted in forty-nine instances only, among the eight thousand seven hundred and fifteen cases of penetrating wounds of the chest. Surgeon J. T. Woods, in the report from Chattanooga already cited, remarks : “ Respiration through the thoracic opening, exhibiting the characteristic mucous bubbling, in cases where the ball could not have failed to perforate the lung tissue, was not a common symptom, but occurred with most certainty when the perforation was in the upper part, and this occurrence was accompanied by much increased difficulty of respiration, — a symptom that was astonishingly slight in those cases in which the above-mentioned mechanical difficulty occurred, or pneumonia supervened.” Brigade Surgeon P. Pineo, U. S. V.,^ attached much importance to this sign. He writes, in the second year of the war : “Of Gunshot Wounds of the Lung, let me say one word: Three cases of a bullet passing through the substance of the lung, producing emphysema, and the air issuing from the aperture made by the bullet, so as to make the case unmistakable, have occurred under my observation, in which the patients recovered. There has been some question about the probabilities of recovery in gunshot wounds of the thorax, and I therefore mention these cases, thinking that you may be interested to know of such favorable results, in so many cases, of so grave a lesion.” Tromatopnoea was observed in only eleven of the cases of which abstracts have been given in this chapter.^ Of these, seven recovered and four died. The lung was wounded in three of the fatal cases, and probably in the fourth. In fifty-one cases analyzed by Dr. Frazer {op cit., p. 52) it was present in seven. This sign of lung wound must be regarded as infrequent and far from pathognomonic. Hoemoptysis. — Until recently most writers on military surgery have taught that spitting of blood soon after the reception of a wound of the chest was a certain sign that the lung was wounded.^ This view, though still maintained by some authors,^ is now known to be erroneous. It is desirable, therefore, to arrive at a correct estimate of the diagnostic value of this symptom. * PlN'EO. Boston Medical and Surgical Journal, 1862, Vol. LXV, p. 373. 2 Cases of Osborne, p. 483; L , p. 485 ; Kdkin, p. 487 ; Brownlee, p. 488 ; Berrien,, p. 491 ; Collins, p. 491 ; L , p. 492 ; Lewis, p. 494; Case 2, p. 510; Dalien and Burke, p. 575. Dr. Ashhurst {Principles and Practice of Surgery, 1871, p. 357) regards tromatopnoea as “perhaps, more characteristic than any other single symptom of wound of the lung,” though he has “ witnessed it in cases in which there was every reason to believe that the pleura alone was injured.” *Bell {Discourses on the Nature and Cure of Wounds, Edinburgh, 1795, Part II, p. 37) says: “If the patient spits blood he fears a wound of the lungs ; if there be an emphy.sema he is sure of it and also at p. 51 : “If spitting of blood and the emphysema, or windy tumour, come on, unquestionably he is wounded in the lungs.” SCIIMUCICEU {Chirurgische Wahrnehmungen, Berlin, 1774, Zweiter Theil, p. 26) speaks of the spitting of blood as evidence of wound of the lung. IlECKEIt, A. P. {Kurzer Abriss dcr Chirurgia Mcdica, Berlin, 1808, S. 793), is of tlie same opinion. Ballingall {Outlines of Military Surgery, Edinburgh, 1855, 5th cd., p. 329) regarded haemoptysis as a more certain sign than the issue of air from the wound in expiration. “Symptoms less equivocal are: Bloody expectoration; severe, urgent, and increasing dyspnoea; insupportable anxiety and faintness immediately succeeding the accident ; these are the most prominent symptoms of a wounded lung.” GUTHUIE (Commentaries, etc., (^th ed., pp. 4.53, 467, 474, 475) is evidently of opinion that haemoptysis, with the passage of air by the wound, is proof of injury of the lung. TliOMSOX, as has been seen (p. 635). regarded tromatopnoea as pathognomon'e, and haemoptysis as a sign of nearly equal certainty. (Bep. of Obs. in Mil. Ilosp. in Belgium, p. 80.) “ That the lungs have been wounded may be inferred with nearly equal certainty.” Lawren’CE (London Lancet, 1830, Lectures, Vol. 1, p. 555) speaks of two circum- stances, which, viewed in combination, showed that the lung had suffered direct injury, viz., haemoptysis and emphysema. Stromeyer (Maximen der Kriegsheilkunst, 185.5, S. 600) says that in shot wounds the lung is always contused, “ wie dies sich auch aus dem Blutspcien ergiebt, welches bci dicssen AVunden niemals fehlt.” Dr. MacLEOD still reiterates (Notes on the Surgery of the War in the Crimea, p. 236) the routine statement “ blood by the mouth and blood and air by the wound are unequivocal proofs that the lungs have been injured.” Assistant Surgeon T. K. BlliNlE, Ist Koyals {London Lancet, 1856, p. 682), reports two cases of recovery from supposed lung wound, the diagnosis being based on the presence of haemoptysis ; IIaxcoCK {London Lancet, 1856. i>. 686) mentions several cases of recovery after chest wounds in which wound of the lung was “evidenced by expectoration of blood.” AIa'ITMEW {Surg. Uist. Crimea, Vol. 11, pp. 315) mentions two case.s in which haem»)ptysis took place, “rendering it highly probable that the lung had been injured.” Si:cT. IV.] DIAGNOSIS AND PROGNOSIS. 637 Mr. Lawson and Dr. Schwartz^ believe that ligemoptysis is invariably present in extensive wounds of the lung only. But there is in the Museum of St. George’s Hospital a preparation from a patient who survived for eight days a laceration of the lung four inches in length by two inches in depth, and had no haemoptysis. Of the cases carefully observed in the Crimea by Dr. Fraser, only one out of nine fatal with wound of the lung had haemoptysis. Of seven fatal cases, in which the lung was not wounded, two had haemoptysis; of twelve cases of recovery, three had haemoptysis. The appearance of this symptom is only noted in four hundred and ninety-two, of the eight thousand seven hundred and fifteen penetrating wounds recorded in Table XXVI, though it might have been present and unmentioned in others. It was absent in the larger number of cases of undoubted shot wounds of the lung, of which specimens are preserved in the Army Medical Museum. Hennen^ recognized that bloody sputa was not indicative necessarily of lung wound. Mr. Blenkins^ also speaks positively on this point: “Haemorrhage from the lungs by the mouth, or bloody expectoration as it is termed, is by no means a certain sign of wound of those organs.’’ • Dr. Appia,^ also, states that haemoptysis is not a pathognomonic symptom of penetration; it may be only the casual complication of some superficial injury.’’ Professor Gross® says: “A discharge of blood by the mouth, however, is not a positive evidence of penetration of the lung, experience having shown that the mere concussion of the chest by a ball or shot is capable of producing it.” Dr. Ashhurst,® likewise, correctly observes that in wounds of the pleura and lung, “haemoptysis is usually, but by no means invariably, present, the expectorated matter being frothy mucus mixed with blood, or more rarely pure blood in considerable amount.” Dr. Chisolm'’^ remarks: “From our large experience of perforating chest wounds, we would infer that the spitting of blood is a very deceptive diagnostic sign of lung wound.” I have adduced, in this chapter, abstracts of nineteen cases in which there was haemoptysis without wound of the lung. Four were unaccompanied by any external lesion. The existence of haemoptysis is noted in only twenty-four of two hundred cases in which the lungs were wounded. Dr. Fraser {op. cit., p. 61), Baudens (op. cit., p. 222), and Matthew {op. cit., p. 314), cite instances of haemoptysis in cases unattended by wound. A similar case was under my care: H. W. Torrey, 27th Massachusetts Volunteers, aged 21. years, a tall, slender recruit, was struck in the left side, September 14th, 1861, by a comrade, in practicing the manual of arms. Copious haemoptysis ensued. Xo fracture. Large moist crepitation was the only modification appreciable on auscultation and percussion. Best and low diet were enjoined, with cold acidulated drinks and salines. He continued to cough up blood, at intervals, for three days, and then rapidly recovered. In view of these facts, it must be concluded that hasmoptysis is of doubtful value as a sign of lung wound, except in conjunction with other symptoms. ^ Lawson, in DruitVs Vade Mecum, 10th ed., 1870, p. 484. ScilWARTZ {Beiirdge zur Lehre von den Schnsswunden, Schleswig, 1854, S. 112^ : ‘’In severe wounds of the lung, a groat quantity of parti}* dark, partly light-colored blood will issue from the mouth and the opening of the wound.” ^IlENNEN (Principles of Military Surgery^ London, 1820, p. 372) : “I have traced a ball by dissection, passing into the cavity of the thorax, making the circuit of the lungs, penetrating nearly opposite the point of entrance, and giving the appearance of the man having been shot fairly across, while bloody sputa seemed to prove the fact, and, in reality, rendered the same measures, to a certain extent, as necessary as if the case had been literally as suspected. Tlie bloody sputa, however, were only secondary, and neither so active nor alarming as those which pour at nvictions as to a future state, and by their social relations in the present. Religionists of equal courage may betray excessive trepidation, or extreme exaltation and confidence in future felicity. Skeptics may contemplate the approach of dissolution with serene indifference, or with remoreeful anguish. Life is dear when gladdened by domestic joys and by success ; little valued when a lonely struggle with adversity. In some diseases, as in cholera, patients com- monly manifest little concern as to their fate. The effects of severe injuries are usually attended by apprehension and anxiety, especially when the great cavities are penetrated; but this is not a uniform consequence. It is most common and characteristic in wounds of the abdomen. A factitious, transitory calmness, indicating, perhaps, that the sympathetic nervous system is overwhelmed, is dreaded by surgeons. Such a condition is occasionally noticed when limbs are torn off. General Moreau's case was an instance. It has been remarked that those dying from sword wounds have a languid resigned aspect, while those killed by shot present a firm defiant expression, and differences in attitude in the dead on the field have also been nottul. (Observations by Chenu, Perier, Brinton.) It is probable that these differences depend very much upon the structure implicated, and are modified as tho mortal wound affects the nervous, circulatory, or respiratory system. (See Sir BEN.TAMIN COLLIXS BuoDIK's Psychological Inquiries. Being a Scries of Essays intended to Illustrate the Mutual Jtelatioyis of the Physical Organization and the Mental Faculties ; in the edition of his works collected and arranged by Mr. Charles Hawkins, London, I860, Vol. I, p. 117.) • / Sect. IV.] DIAGNOSIS AND PKOGNOSIS. 639 from loss of blood, and those dependent on lesions of the nervous system, and on mental and moral causes. If this were always done, there would be fewer vague descriptions of shock and of conditions of undefinable, indescribable anxiety and nervous depression. Authors assert that patients with penetrating wounds of the chest frequently die from shock, when dissection reveals no appreciable mortal lesion. I have never met with a case of the kind, nor with a carefully written observation corroborating this assertion. Surgeon Baruch describes (p. 610, ant^ an expression of anxiety as very peculiar in penetrating wounds of the chest ; but I am satisfied that this expression is much less common in such injuries than in penetrating wounds of the abdomen, and that the explanation is to be sought in the lesser implication of the sympathetic system of nerves in chest wounds. Other /Signs . — ^Apart from emphysema and lumbar ecchymosis, which have been discussed, the other signs of penetrating wounds of the chest are those attendant on haemorrhages, and those that accompany inflammations or intrathoracic effusions, and those connected with the appearance of the wound, and in some instances of the weapon. The signs due to haemorrhage have been referred to on pages 519, 530, and 624, in treating of wounds of the blood-vessels, and of the heart, and of haemothorax. Great attention should be directed to the detection of the bleeding point when the situation of the wound indicates the probability of a lesion of the intercostal or internal mammary arteries. A spatula or curved piece of card-board introduced between the lips of the wound may render the source of the haemorrhage visible, or the finger introduced may feel the warm arterial jet; or it may be requisite to enlarge the wound. The chest should be exposed and cold applied while the search is prosecuted. The feeble pulse and clammy skin will reveal, and auscultation and percussion will guide, in the more copious haemorrhages. In rare instances of wounds in the sternal, subclavian, and axillary regions, the pulsation of the great vessels and even of the heart may be seen.^ The physical signs derived from auscultation and percussion furnish the most reliable indications in the consecutive inflammations and effusions, and will be interpreted in connection with the rational signs. Though, immediately after the reception of the injury, there may be moist crepitus, the gurgling of tromatopnoea, various friction sounds absence or diminution of the respiratory murmur, and modifications in resonance, the surgeon will listen in vain for uniform sounds characteristic of particular lesions.^ If there be a wound of entrance only, the presence of a foreign body, in a shot wound, will be suspected, but not positively affirmed, for the missile may have dropped out or have been removed with the clothing. If there are two wounds, the surgeon will not conclude hastily that one is necessarily a wound of exit ; for it may happen that the man has been struck by two balls and that both have lodged. This subject of the diagnostic signs of entrance and exit apertures, will, however, be fully discussed in the chapter on ^ See HENNEN’s case LXII {op. cit., p. 395), Lieut. Colonel II , wounded at Waterloo, under the centre of the left clavicle: “1 was very curious to see the state of the artery ; it lay awfully pulsating in sHu, which uncovered arteries are not always obsen’cd to do.” See also Proh'ssor Billroth’s cases already referred to, and a number cited in this work. * Though refusing to accept Jobert’s and BouillaUd’s bruits dt frottement as distinctive and pathognomonic indications of wounds of tlie heart, I would by no means depreciate, in the slightest degree, the value of physical exploration in such cases. One cannot but read with a touching interest the recent lectures of Professor Piorry on the utility of percussion in the diagnosis of chest wounds. Though desolated by the afflictions of his country, the veteran professor says that he wishes to impart to the young surgeons whatevei m a physician can olTcr, and has, therefore, printed this scries of discourses on plessimetrism, an art, which, in the perfection to w’hich Pn^fessor Piorr nas carried it, will perhaps perish with him. ®Mr. EiilCHSEN, The Science and Art of Surgery, 5th ed., Vol. I, p. -134, says that in wounds of the lung: “On auscultating the chest immediately after the infliction of the injurj’, and before there is time for the sui>ervention of any consequences, a loud rough crepitation will be distinctly audible at and around the seat of injury.” The surgeon docs not have an opportunity of examining the wound before there is time for the effusion of blood. At the earliest moment he can examine, he may or may not hear loud rough crepitation, near or distant, according to the extent of the wound and the amount of effusion in the larger air-tubes. GiO WOUNDS AND INJURIES OF THE CHEST. [Chap. V, gunshot wounds in general.^ The surgeon will gain all the information he can from observing the external wound, using his finger, as far as he judges prudent, to determine the extent of the wound, and the presence or absence of foreign bodies, but not employing the probe in early examinations- He will next endeavor to ascertain if the lung is wounded. S. Cooper directs to “ make the patient expire strongly; during the succeeding inspiration, as completely as possible to cover the wound, to prevent the entrance of external air ; after once or twice repeating this process, if air continues to be expelled, the lung must be wounded;” but this plan can hardly ever be made satisfactory, even with the aid of the flame of a taper. Th einjection of liquids into the cavity to determine this point is dangerous, and has long since been condemned. In stabs and sword thrusts, something may be learned from the extent in which the weapon is stained with blood. The aid that may be derived from placing the patient in the posture in which the wound was received, will not be forgotten. However ingeniously and skilfully the examination may be con- ducted, there are many cases in which the surgeon must be contented to remain in doubt, and to refrain from hazardous explorations. The extensive and varied data adduced in tlie discussion of the mortality of chest wounds, and especially in relation to penetrating shot wounds, furnish a reliable basis for a general prognosis. The prognosis of individual cases must be formed from the special circumstances attending them. In the footnote^ may be found the aphorisms on this subject formulated by John Bell. The practitioner will bear in mind that the chief early danger is from heernorrhage, and will remember the encouraging assurance of the experienced Hennen,^ on the hopefulness of the case where ‘‘the third day has been safely ^ I\Iedico*legal questiuns may sometimes depend upon the solution of this point. A Confederate officer was confined in the military’ prison at Norfolk, in 18G3, under sentence of death for murder. 'NVhile in bed, he was shot through the left chest, by the colored soldier at his door, — the smooth- bore musket, in the sentinel’s hands, being charged with a round ball and three buckshot, the distance from the bed to the sentinel's post being about twelve paces. A little below and witliin the left nipple were three wounds, one large and two small, the edges blackened, stellate, slightly inverted. Between the spine and lower angle of the left scapula was a single wound, large and ragged. This was on a plane two inches and more lower than the anterior wound. There was profuse haemothoras, and the patient died in thirty -six hours. Aware of his approaching end, he stated that he had raised himself in bed to change his position, and that the sentinel appeared at the door and ordered him to lie down, and fired almost immediately after, the cdiarge taking elfect in his left breast. The sentinel testified that the officer sat up in bed and was endeavoring to raise the adjacent window, — that he thrice ordered him to lie down, and then fired, W’hen the officer's back was toward him. The sergeant of the guard testified that the sentinel was instructed to fire, if the prisoner attempted to escape. At a court of enquiry, it was argued on the one hand, that the three anterior wounds were wounds of entrance, that the buckshot had probably lodged, and that the ball with its greater momentum had emerged at a lower plane. On the other side, it was contended that the ragged posterior wound marked the entrance of the entire charge ; that the three anterior wounds marked the exit of the ball and buckshot. ^ John Bell (op. ci^., Part II, p. 51) embodied his views of the prognosis in the following series of aphorisms: “1st. If the patient lies oppressed, tossing, insensible, his face ghastly, and his extremities cold, his condition is very doubtful, it looks much like a wound of some vessel near the root of the lungs ; and if so, he is surely gone. 2dly. If the oppression come on more slowly, the pulse only hurried and fluttering, and the extremities not so cold, there is reason to hope that his wound is merely in the edges of the lungs ; and, as it is at a distance from the great veins and arteries, he may escape. 3dly. If spitting of blood, and the emphysema, or windy tumor comes on, unquestionably he is wounded in the lungs ; but that wound is not always fatal. If either the blood do not flow in upon the lungs in great quantity, or if, by our profuse bleedings, that bloody exudation into the lungs can be restrained, then he may’ be saved. 4thly. If, when there is muoh oppression, we put our finger into the wound, let some blood out, and so give relief, we are sure that the sufl'oeation proceeds from blood extravasated in the thorax ; and that kind of suftbeation we know to be less dangerous by far than that i)rocecding from blood poured into the proper cavity’ or cells of the lungs, i. e. int() the air-cells into which we draw the breath, and which, while they should be filled with air, are choked with blood. 5thly. If a bullet jiasses fairly through and through, the patient is safer; he is in great danger, if it stops, whether within the thorax or in the lungs ; for when it passes through, as soon as we have saved him, by bleedings, from the first dan'^’crs, he is sas’ed. But when it remains within the chest, he is exposed to tedious suppurations, incurable sores, hectic, wasting, and death; and nothing so wearies the surgeon, or depresses the patient’s hopes, as an unceasing flow of matter, and a fistulous sore ; nor can anything be more distress- ing to the surgeon than the seeing a patient slipping through his hands (to use so vulgar a phrase), more especially’ if, during a lingering distress, he has thought it necessary to sui^poii the friends with hopes and promises; for then it falls peculiarly’ on all concerned, — on the surgeon, who has suggested or allowed such hopes, as well as on those who have permitted themselves to be thus deceived.” 3 Among the various authorities on the prognosi.s, we find that IlENNEN (Mil. Surg. 3d od. p. 391), while “unwilling to lull cither a patient or a surgeon into a false security’, or to underrate the real dangers <.'f any’ case,” has “seen many’ wounds of the tliorax, both from pike and sabre thrusts, and from gunshot, do well ultimately ; ” that he “cannot but hold out great hopes where the third day’ has been safely’ got over; fur, though occasional hsemopty’sis may’ come on at almost any’ period during a cure, and its approach can neither be entirely’ prevented nor anticipated, the more deadly hJEmorrhages arc usually within the first forty’-eight hours ; and y’ct to this alarming symptom, when within moderate bounds, the safety’ of the sufferer is often due.” This guarded statement and the often-quoted remark of Dr. Gregory*, of Edinburgh, that of twenty’-six wounds of the thorax received at the battle near (Quebec, two only’ were fatal,” have undoubtedly' had much influence with jiractitioners in this country’, in their prognt)sis of chest wounds, having been repeated with approval, for many y’ears, in our leading medical school, by’ Professor W. Gibson. Sir Geouge BallinGALL taught (Outlines, etc., 5th ed.) that “the expanded surface of the thorax renders wounds of this region frequent in battle, while the vital importance of the organs lodged within it render them peculiarly dangerous.” GuTinilE {Comm. p. 4G2) is of opinion that “gunshot wounds of the chest, penetrating the SiCCT. IV.] DIAGNOSIS AND PROGNOSIS. 611 got over;” but will not forget that Ilennen had to deal with wounds inflicted by the sword and pike and missile of the “old Brown Bess,” and that the elongated heavier balls employed in modern warfare causes injuries more deadly. While using every precaution to arrest inflammatory complications and strictly enjoining low diet and absolute rest, he will not anticipate pleurisy and pneumonia as necessary consequences, or indulge in prophy- lactic depletory medication; he should dread effusions more than inflammations. If he can save a third of the patients that are wounded in the lung he may esteem himself happy, and the survivors thrice fortunate. The lamented Tripler, in his excellent lecture on Wounds of the Chesty while admit- ting that the signs of wounds of the lung are singly equivocal, regrets the exceptions taken by Dr. Fraser to the generally received views “as calculated to do injury in inexperienced hands, by unsettling opinions in very plain cases, thus leading to indecision in practice and uncertainty in diagnosis.” It is, therefore, proper ^to say that in indicating the uncertainty of individual signs, the object here had in view is rather the encouragement of the inexperienced in the careful investigation of cases, as Dr. Gerhard was wont to do, in his unsurpassed clinical instruction, when he constantly dwelt upon the fallacy of individual symptoms and- exhorted the student to familiarize himself with the “whole case.” It may further be proper to reiterate that a majority of the signs discussed, when existing in conjunction, may establish the diagnosis with a precision little short of certainty. I cite, in foot-note, Samuel Cooper’s rules" for making out the diagnosis in incised wounds of the chest, remarking that intra-pectoral injections are not now considered per- missible; and a quaint extract from the oldest work^ on surgery printed in English, on the means of determining wounds of the lung by the passage of air. I will add that in the latest contributions on the surgery of the late Franco-German war, the influence of*the size of projectiles upon the fatality of shot wounds is particularly insisted on, and the diminished mortality ascribed, in a measure, to the small bulk. of the chassepot missile compared with the large conoidal balls used in most muzzle-loading arms. And, lastly, that there has been little investigation of the state of animal temperature in cases of severe wounds, and that aid in the prognosis of chest wounds may be sought in careful thermo- metric observations. cavity, are always exceedingly dangerous.” Mr. G. LawsOX (Druitt s Surgeon's Vadc Mecum^ 10th ed., 1870, p. 124) says, “the prognosis in all pene- trating wounds of the chest is unfavorable, particularly if the ball has lodged.” On the other hand, JOHN Bell declares {Princiides of Surgery, ed. 1820, Vol. 1, p. 431, and Discourses on the Nature and Cure of Wounds, Part II, p. 3) “a wound of the substance of the lung is liir from being mortal.” Among German authors, RiCHTEii {Anfangsgriinde der Wundarzneykunst, Gottingen, 1800, B. IV, S. 326) says: “Lung wounds arc generally dangerous on account of the fatal loss of blood, of the effusion of blood into the cavity of the chest, or of pneumonia.” Schwaktz, H. {Beitrdge zur Lehre von den Schusswunden, Schleswig, 1854, S. 114), remarks: “Die Prognose der Brustwunden mit gleichzeitiger Lungenverletzung ist ohne Ausnahme eine sehr ungunstige. * * * Sind fremde Korper, als Kugel, Kleidungsstiicke, Rippensplitter in der Lunge selbst oder auch nur im Pleura-Sack geblieben, so ist die Prognose urn so schlechter.” Among the French, the opinions of Ravaton, LaMotte, and others have been cited. Vidal says (Traite de Path. Ext. et de Med. Op., 5dme 6d., T. IV, p. 71) : “ Wounds of the lungs are certainly dangerous ; but if compared with wounds of other viscera, the prognosis will appear relatively less grave. A wound of the heart, a wound of the brain, of the viscera of the abdomen, all things being otherwise alike, are graver than wounds of the lung.” ^ Teipleii, Handbook for the Military Surgeon, Cincinnati, 1861, Chapter VI, p. 74. I have not often referred to this admirable compendium, presuming that its contents are as “familiar as household words” to Army medical officers. 2 Cooper, A Dictionary of Practical Surgery, 1838, Vol. II, p, 481 : 1. Placing the wounded person in the same posture in which he was when he received the wound, and then carefully examining, with the finger or probe, the direction and depth of the stab. 2. The examination, if possible, of the weapon, so as to see how much of it is stained with blood. 3. The injection of fluid into the wound, and attention to whether it regurgitates iinin(?di* ately or lodges in the part. 4, The color and quantity of the blood discharged from the wound are to be noticed, and whether any is coughed up. 5. Wo are to examine whether air escapes from the wound in respiration ; and whether there is any emphysema. 6. Lastly, the state of the pulse and breathing must be considered. 3 In Chapter XLVIII, “ Of the wounde in the brest,” in the English version of Jiikrome OF BnVYXSWYKE’s “ The noble expcryence of the vertuous handywarkeof surgeri," printed “in the ycrc of our lordc God MDXXV, and the XXVI day of Manflie (reputed the first work 1(5 ■\VOUi\J)S ANP INJURIES OF THE CHEST. [('IIAI'. V, after profuse loss of blood, and will be guarded in its administration under such circum- stances. hledical Director Ilewit found great advantage in introducing the salts of morphia by dusting them and rubbing them in upon the surface of wounds, and this practice was frequently adopted by the surgeons under his direction, and was reported to allay local pain very promptl}^. The hypodermic method was also frequently employed. I think Dr. Squibb is right in pronouncing pure opium, in substance, more reliable than any preparation. Calomel. — On account of their supposed control over inflammatory processes, mer- curial preparations were much employed in traumatic pleuritis and pneumonia. They may be requisite in combating the tendency to exudations in carditis, and with a view to promote the absorption of serous effusions in the pleural cavity. But the estimate of their efficacy in the earlier stages of inflammation following penetrating wounds of the chest has steadily declined of late years, and probably has not yet reached its proper level. Mr. Wharton^ has ably directed attention to the fact that sufficient importance has not been paid, in the treatment of these lesions, to the necessity of maintaining the blood in such a condition as to favor its coagulability, on which the natural reparative process depends, and that great caution should therefore be exercised in administering aiiy drug likely to appreciably diminish the normal proportion of fibrin." Antimonials. — Tartrate of antimony and potash^ was employed to a limited extent to reduce the force of the circulation, and aid in the suppression of hsemorrhage, and also to combat consecutive inflammations. But this remedy shared in the discredit into which venesection had fallen, and was little relied on by Union or Confederate surgeons. Veratrum UirffZe.— The rhizome of the American hellebore or Indian poke, })repared as a tincture, was sufficiently valued to be admitted and retained on the Army Supply Table. “ For controlling the circulation, liberal use,” Professor Gross ^ teaches, “ should be madd of veratrum viride, its effects being carefully watched, lest too much cardiac depres- sion should arise.” The favorable estimate of its utility in traumatic pneumonia entertained by Surgeon Woods, is recorded on page 620. It was much esteemed by other experienced surgeons. I believe that any good results to be obtained from it, may be arrived at with greater certainty and safety by using antimonials combined with narcotics.® Aconite. — Pharmacologists reckon this arterial sedative as useful in active haemorrhage and in inflammations, and it appears to have been, with a few surgeons, a favorite remedy in some of the complications attending wounds of the chest.® - * Wharton. Two Cases of Penetrating Wounds of the Chest. Dublin Quar. Jour, of Med. Sci., Vol. XL, 18C5, p. 111. The author regrets that in the management of one of the cases he had recourse to the exhibition of mercury, even to a limited extent. 2 By Surgeon General IIammoND's Circular No. G, S. G. O., May 4th, i8G3, calomel and tartar emetic were directed to be stricken from the Army Supply Table, on the ground tliat ‘‘no doubt can exist that more harm has resulted from the misuse of both these agents, than benefit from their proper administration.” Both resumed their places in the Standard Supply Table promulgated in Circular No. 6, S. G. O., l^Iay 0th, 18G7. 3 ‘‘It is but rarely that the sedation produced by nauseants, such as antimony and ipecac, can be of judicious application in a case of profuse traumatic liffimoryhagc, threatening a fatal termination. Such remedies depress the vital powers too decidedly, and yet often fail to arrest the sanguineous flow. Antimonial preparations are often injurious, if long continued, by their disorganizing effect on the blood.” — Manual of Mil. Sur. for the use of the Con- federate States Army, Richmond, 1863, p. 97. DemME, reviewing the therapeutic management of chest wounds after the Italian War of 1859, remarks {Militdr-chirurgischc Studien in den Jtalienischen Lazarethen von 18.59, Wurzburg, 1861, B. II, S. 114): “I cannot sufficiently caution the army surgeon against the routine treatment by tartarized antimon}’’ in the majority of cases.. It must not be forgotten that our cases are entirely different from those of the medical practitioner in diseases of the chest. When it is necessary to reduce arterial action, digitalis or veratria should be used.” * Gross, A Sgstem of Surgery, 1872, Vol. II. p. 447. Refer also to Professor GEORGE B. WOOD {A Treatise on Therapeutics and Pharmacology^ Philadelphia, 1868, Vol. II, p. 1.53) ; Professor WILLIAM Tully (J/aZerta J/edfea or PZiarmacofo/;?/ and JherapcuiicSt Springfield, 1858, Vol. I, Part II, p. 927). See Surgeon Crosry’b remarks (Aitendix, p. 1 1), and those of Surgeon PllELl’S (Appe.sdix, p. 262) ; PERCY {Trans. Am. Med. Assoc.., 1864) ; Bullock (Am. Jour, of Pharm., Vol. XXIX, p. 204, and March, 18GG, p. 98) ; NORWOOD, Va. Med. and Sarg. Jour., Vol. I, p. 198. ® Pharmacologists arc not agreed as to the number or physiological effects of the alkaloids in veratrum viride. I have often obseiwed the effects of the administration of this remedy in cases of pneumonia, in the practice of Professor Tally, who intr- duced the remedy, and in the practice of his disciples, and thus became convinced of its uncertainty, and liability to produce, in large doses, toSric effects analogous to those caused by tobacco. See Pereira, The Elements of Materia- Medica and Therapeutic.^, 3d Am. ed., 1854, Vol. 11, p. 1085, and Kdinh. Journ. of Mat. and Gtogr. Sci., July, 18G0, p. 235, and FLEMING, An Inquiry into the Medicinal Properties of the Acotiitum Napcllus. 1 knew of two instances of fatal poisoning of officers, through mistakes in dispensing the strong liucturc of aconite at the field dispensaries. See ORFILA, Traitc dc Toxicologic, 5t.ine cd., 1852. Sect. IV.] GE'S'EllAL TKEATMEA’T. G47 Digitalis. — This medicine, usually in the form of alcoholic extract, was often employed; hut did not obtain that general confidence which is placed in its remedial powers by the Russian military surgeons. It was used as a succedaneum. Surgeons generally did not accept Dr. Fuller’s views as to its physiological action, and followed the precepts of our eminent teacher. Professor AVood, in its therapeutical ap])lications.' Hyoscyamus was occasionally used as a substitute or adjuvant to opium, oi’, in com- bination with colo^mth, in purgative pills.^ Acetate of Lead. — The neutral acetate was emidoyed not infrecpiently in hsemoptysis, and in cases complicated with diarrhoea, and was usually combined with opium. Sometimes saturnine lotions were used to moisten the compresses placed on irritable wounds.'^ Gallic Acid. — Gallic acid, tannic acid, and vegetable astringents in substance are mentioned among the prescriptions in cases of chest wounds, especially in those in which there were hsemorrhages or intestinal fluxes.^ Saline and Other Purgatives. — Sulphate of magnesia, Rochelle salt, jalap, colocynth, and the compound cathartic pill of the pharmacopoeia, were sometimes employed; but usually the patients had loose bowels already, and these remedies, and laxative enemata, were not often called in requisition. A few surgeons, mindful of the ancient haemostatic credit of sulphate of soda, prescribed a black draught with glauber salt, when purgatives were indicated. AVith the same motive, turpentine was occasionally made a constituent of purgative and expectorant mixtures.® Hydrochlorate of Ammonia. — Sal ammoniac was used to a very limited extent in the progress of cases followed by pneumonia, but did not enjoy the favor with which it is regarded by the German military surgeons. Its admitted liquefactive influence upon the blood should contraindicate its administration in haemorrhages and traumatic pneumonia.® Tonics. — Dilute aromatic sulphuric acid in sweetened water was a favorite prescrip- tion for a drink for patients who had suffered from haemorrhage. The salts of quinia were largely used in cases with malarial and pyaemic complications. Arsenic was employed, though much less frequently, in similar conditions. Ferruginous preparations and vegetable tonics were administered during the convalescent stage. ^ Stimulants. — Diffusible stimulants were much used in the depression immediately following the reception of the injury, and often injudiciously and without medical advice, and reaction and the danger of haemorrhage were thereby augmeiited. The cautious use of ammonia and brandy was requisite in cases attended by great prostration- at the outset.® In the later stages, alcoholic stimulants and carbonate of ammonia, in conjunction with concentrated nutriment, were important adjuncts to the restorative treatment. Ergotinc was prescribed as an hsemostatic in a few instances, but no evidence of its utility is given. ^ Consult Wood (A Treatise on Therapeutics and Pharmacology^ Phila., 18G8, Vol. II, p. 103); GUDLEii {Commentaires TherapeutiqueSy Paris, J868, p. 103) ; Homolle and Quevenxe (Arch, de Physiologic, 1854, p. 223) ; TitAUBE (Ai'ch. Gen. de Med., T. XXVIII, p. 338). 2 On its effects, consult LEMATTRE, Arch. Gen. de Med., Aodt, 1865, p. 186; GaN'OD, Med. Times and Gaz., Dec., 1857, p. 589; SCIIROFF, Wochefi' hlatt der Ges. dc.r Aerzte zu TVten, Juni 16, 1865; Stille, Therapeutics ajtd Materia-Medica, 3d ed., 1868, Vol. I, p. 765. * Consult Goulard, Traill sur Us ejfets des preparations deplomh., Pezenas, 1760. ^ Refer to Weaver, Am. Jour, of Pharm., Vol. XXIX, p. 82; GUBLEU, Commentaires Thlrapeutiques, p, 579; Gmelin, Chimie Organique appliquee d la Phys. ei d la Med., Paris, 1823; and papers by Drs. Neale and Grantham and M. Saumon. ® Wood and Bache, The Dispensatory of the United States of America, 12th ed., 1865, pp. 792, 828; HAMILTON, Observations on the Utility and Administration of Purgative Medicines in Surgical Diseases, Edinburgh, 1815. * Consult Gubler, Commentaires Thlrapeutiques, 1868, p. 403. Forits employment in inhalation, see DacOBTA, Inhalatioi-is, etc., pamphlet, p. 86, Phil., 1867; GarROD, The Essentials of Materia- Medica and Therapeutics, London, 1868, p. 49. ^ See Carson, Synopsis of the Course of Lectures on Materia- Medica and Pharmacy delivered at the University of Pennsylvania, Philadelphia, 1851, p. 72; ROYLE and Headland, A Manual of Materia-Medica and Pharmacy, 3d ed. ; TULLY, Mat. -Med. and Phar., Vol. I, Part 11, p. 1103; Baylk, Bibliotheque de Therapeutique, 1837, T. IV, p. 222: LlNDLEY, Flora-Medica, London, 1838, p. 426; UAFriNEsQUK, Medical Flora, Philadelphia, 1828, p. 206. * Consult Forbes, Physiological Effects of Alcoholic Drinks, Boston, 1848; Aitken, The Science and Practice of Medicine, 3d ed., London, 1864, Vol. II, p. 691 ; Bennett, Clinical Ler.tures on the Principles and Practice of Medicine, 2d Am. cd., 1863, p. 646 ; ASHIIURST, Prin. and Pract. of Surg., 1871 : " Beef-tea and even brandy will, according to my experience, be more often required in cases of lang wound than calomel or autimon}',” p. 359. 648 WOUNDS AND INJURIES OF THE CHEST CONCLUDED. [Chap. V, Epispastics. — Ijai'go blisters were recommended by high authority^ and were often emj)loyed in cases of traumatic pneumonia, even in the early stages. There wore many surgeons who considered their efficacy in controlling inflammatory processes sufficiently great to counterbalance the suffering they caused, the hindrance to auscultation and percus- sion, and liability to gangrene and diphtheritic infection their raw surfaces presented. Doubtless a wise selection and combination of some of these remedies may materially modify and shorten the duration of some of the complications of wounds of the chest; but, with the exception of opium, they are all subsidiary to the operative treatment, the rigid enforcement of mental and physical rest, the regulation of the air, and of the diet. The latter should be severely restricted at first, and, though later, nutritious food is of advantage, it should long bo of liquid form and easy of assimilation. I dwell upon this jioint, because the reports show that many surgeons erred in allowing solid animal food at too early a period.^ • See Gross, A System of Surgery, Vol. II, p. 447. 2 Stadlander, JJiss. de pulmovum vtdn.. Franc., 1683 ; CrceseR, J. H., Dissertatio dc thoracis vvlnerihus, Lngduna IlatavoiTim, 1716 ; KCOY, A., Pissertatio de vulnerihus thoraces, Fugduni, 1738; Frickk, J. H. G., Dissertatio de covtusionihus Gottingen, 171)2; llERHOLDT, Demerh ungen iiher die chirurgische Bchandhwg tiefer Wunden dcr Brust, Kopenhagen, 1801; VERllsG, iJber die cindringenden Brustwunden, 4to, 'NVien, 1801; IvUMl’BE, E., Dissertation sur les Plaics d'Armes d fcitpcnHrautcs dans Ja Poitrine, 4to, Paris, 1814 ; BauDON, Dissertation sur le.s plaies pcnctrantes de jmitrine, 1815, These de I* *aris, No. 3G6; Fauret, F., Dissertation sur les penetrantes de poitrine, etc., 1823, These de Paris, No. 107; Mayer, C., Tractatus de vvlnerihtis pectoris 2 '>encirantihus imjirimis cum. Ilacmorrhagia covjunctis, Heidelberg, 1823; FRASER, P., A Treatise upon Penetrating ^'ounds of the Chest, London, 1851). Dr. Fraser gives a list (p. 14) which I take the liberty to quote, of all the cases of penetrating wounds of the chest recorded in the Lancet, Medical Times, Medical Gazette, and Medico-chirurgical Transactions from their commencement: “Laxcet, 1832, August 11th, p. 604; October 27fh, p. 151); 1838, June 2d, p. 350; 1841, August Hth, p. 724; 1846, Slay Sth, p. 533; 1847, January 8th, p. 67; 1851, April 6th, p. 416; 1852, February Hth, p. 193; 1856, June 21st, p. 682, and p. 685; MeuiCO-CiiIRURGICAE Traxsactions, 1825, Vol. VII, p. 315; 1826, Vol. IX. p. 204; 1841, October, p. 564; 1842, October, p. 615; MEDICAL Gazetie, 1828, Marcb 29th, p. 512: 1820, October 24tb, p. 124; IH30, Januaiw 16th, p. 520; 1835, IMay 2d, p. 146; 1837, November 18tb, p. 302; 1838, August ISth, p. 802; 1840, February 7th, p. 721 ; 1843, Jday 20th, p. 322; 184.5, September 26th, p. 980; 1847, January 22d, p. 13ti2; 1849, March 16th, p. 483; 1850, October 18th, p. 713; MEDICAL TIMES, 1844, April 6th, p. 21 ; December 7th, p. 231 ; 1847, August 20th, p. 512; April 8th, p. ; 1853, December 17th, p. 638; JIEDICAL TIMES AND GazeITE, Vol. XXXVI, pp. 242, 604.” For practical observations on gunshot wounds of the chest during the 5Var of the Rehcllion, sec Appendix to Part /, of the Medical and Surgical TUstory, as follows : By Surgeon A. B. Crosby, U. S. V., p. 11 ; by Surgeon C. S. Wood, Gtltli New York Volunteers, p. 88 ; by Assistant Surgeon J. S. Billings, U. S. A., p. 200; by Surgeon A. J. Phelps, U. S. V., p. 261; by Surgeon W. W. Blair, 58th Indiana Volunteers, p. 263; by Surgeon D. G. Brinton, U. S. V., p. 293; by Surgeon H. S. Ilewit, U. S. V., p. 312. In the American medical periodicals, the following articles may be found, in uiblition to those already referred to : G.\LLOUPE, Gunshot )yound of Chest ; Ball removed after seventeen years, Boston Med. and Surg. ■lour., N. S., 1872, Vol. IX, p. 267 ; Kirkijimde, T. S., Gunshot JVound of the Thorax, Am. Jour. Sled. Sci., Vol. XV, p. 357, O. S., 1834 ; D'Avicnon, F. J., Extensive iro««d of the Tltorax, Jtccovery, Boston Med. and Surg. Jour., Vol. XXXIV, p. 231, 1846; BlantoN, A. IM., Case of Gunshot Wound of (he Chest, Am. Jour. Med. Scj., Vol. XVII. p. 23, 1849; HOOKER, A., Penetrating Woundof the Chest, Death in eighteen days, Boston IMed. and Surg. Jour., Vol. LXII. p. 223. i860: AsililL’RST, J., Jr., Casts of Penetrating Wounds of the Chest and Throat, illustrating some imj^ortant Practical Points, Am. Jour, I\Ied. Soi., Vol. XLIII, p. 61, 1862; LOMBARD, J. S., Case, of Pneumonia following Gunshot Wound of the Chest, Boston liled. and Surg. Jour., Vol. LXVIll, p. 471, 1863; CABOT, Gunshot Wound of (he Chest, Boston Med. and Surg. Jour., Vol. LXVIll, p. 100, 1663; WALES, P. S., Gunshot Wound of the Chest, Am. Jour. Med. Sci.. N. S., Vol. XLV, p. 380, 1863; SMILEY’, T. T., Gunshot Wounds, from Arkansas Post, Two Case^ of Chest Wounds, Boston Mod. and Surg. Jour., Vol. LXIX, p. 153, 1863. The following references may also be advantageously consulted ; WarREN, J. IM., Wound in Chest from Grapeshof, Surgical Observations, with Operations, Boston, 1867, p. 550; CARRE, M., Considh'ations sur les Plaics de la Poitrine, compliquees de Lesions aiix Poumons, in Pec. de M6m. de Med., Paris, 1826, T. XIX, p. 144 ; Gama, Observation d'une Plait Penetrante de la Poitrine., Pec. dc Mem. de Med., Paris, 1822, T. XII, p. 177; IIIRN, Observations sur une Plait Pcnetrantcdela Poitrine, suiviedeV ExjmUionde plusicurs J*vrlions de la Membrane muqueuse qui tapissc V intrricur de la Trachh aricre, Pcc. de Mem. dc Died., Paris, 1819, T. VI, p. 276; Kries, II. ()., De Vulncribus l*cctoris Penetrantibus, Berolini, 1828; PecIILIN, J. N., Sisiens Jlistoriam Vulneris Thoracis e.t in cam Commentarium in Halleu's Dispiit. Cbir. T. n. p. 531; Scil.MID, H., Ueher Penetrirende Brustwunden, Jena, 1867; PlCHTER, A. G., Anfangsgriinde dcr Wundarzncyl’unst, Gottingen, 1860; SacMERING, S. T., De Morbis Vasorum Ahsorbentium, Trajceta ad Moen, 1795; IlEURMANN, G., Abhandlung dcr Vornchmsten Chirurg. Gperationen, Kopenhagen und Leipzig, 1756: ValenTIN, de qmitrine ai'tc ipanchement ; dcs signes des epanchements dc sang, etc., in Jicch. crit. sur la chirurgie moderne. Paris, 1762 ; MarJOLIN, Dictionnaire cn 30 volumes, 1842, T. XXV, p. 413 : Anger, B., Plaics Penetrantes dc Poitrine, Paris, 1866. * Besides the specimens already referred to, the following preparations in the Army Medical Museum, Section 1, illustrate shot wouiUls of the bing : Si>ec. 603. — “ A wet iirejiaration of the left lung, showing ulceration of the apex, following gunslnjt. Private W. B. T., Co. E, 4lh Maine Volunteers A bullet entered to the left of the seventh cervical vertebra, and was cut out on the field, just behind the right btemo-cleido-inastoidcus, opposite the fourth cervical vertebra, Fredericksburg, December 13th; admitted bcspitul, Washington, December It'th; hajniorrhagc from the anterior wound and cough appeared on 21st ; air issued from p(;Rtcrior wound on 27th ; died on 28th Decomher, 1862. The right humerus was fractured near the elbow, also. Contributed by Acting Assistant kSurgeoii F. P. Sprague” {Cat. Burg. Sect. Army Med. Museum, p. 480). Spec. 606. — ” A preparation of the right lung, showing a perforation of the apex, followed by ulceration. A bullet entered near the stenio-clcido-mastoideus, three-fourihs of an inch above the clavicle, and escaped an inch to the right cf the fourth dorsal vertebra. The specimen is badly cut, as if in dissection. Private V. B. C., Co. C, IGth Maine Volunteers; Fredericksburg, 13th December; admitted hospital at Washington on 18th; cough appeared on 2Cth; haimorrhages from anterior wound until 24tli; died 3Cth Decemher, 1862. Contributed by Acting Assistant Surgeon F. P. Sprague” {Cat. Sio'g. Sect. Army Med. Mu.^icum, p. 479). Sqiec. 960. — “ A preparation of a portion of the left lung, with a battered ecnoidal ball lodged near the apex. M. F., 88th New York Volunteers; Antietam, September Hth, 1862; admitted hosjntal at Frederick on 21st, with gunshe t fracture head cf humerus, which was excised on the 2.5th : died cn October Sth, 1863, from pleuro-pneumonia” (Cat. Surg. Sect. Army Med. Museum, p. 478). In all wars much valuable pathological material is wasted. Klels, E. {Beitr'dge zur Patholvgischen Anatomic der Schusswunden, Leipzig, 1872. note, S. 123). ”1 may be permitted to express my regrets, that the large material under Billroth’s direction, as regard jmthological anatomy, was not entrusted to a teehnioally-oducatod investigator, as was done at Carlsruhc. Where every surgeon makes his own collection of specimens, the material becomes scattered, and only so much of it will be preserved as is of sc*ciille«l chirurgical inij)ortance, a term of frequently very doubtful significance.” Sfxt. IV.] GENEEAL TREATMENT. 619 There are a certain number of cases of penetrating wounds of the cliest that will prove fatal in spite of any treatment, and a certain number will recover if left to them- selves. Between these extremes lie a number of cases, some of which will recover, if properly treated, who would otherwise have died, and some will recover perfectly, who would have been left with damaged organs if no treatment had been employed. And it is in regard to the treatment of these manageable cases that it is most difficult to lay down positive rules. They are those in' which experience is so useful, and the appreciation of shades of difference scarcely to be expressed in words ; but recognized by the educated eve and ear and hand of the enlightened and accomplished surgeon, who has attained that point where scientific principles seem almost to merge in the application of the rules of art. Such a practitioner possesses knowledge which he cannot convey didactically. It may be noticed that our foremost systematic writer on surgery still teaches, in the last edition of his work,^ that the strictest depletory measures should be employed in penetrating wounds of the chest, and the most rigorous antiphlogistic regimen, — provided, always, that “the system has not been too much drained of blood by the accident,” and “the pulse is full and hard and frequent,” and the countenance is “hot and flushed.” Whereas, “if the reverse be true,” lowering agents should be refrained from. Yet, though, during the war, he continually visited the military hospitals in various parts of the country, and gave, whenever his laborious avocations permitted, the benefit of his wise counsel and matured experience to his junior brethren, and must have encountered many cases of injuries of the chest, he appears never to have met with one, at a juncture when the depleting measures he recommends could be considered opportune. Dr. Fraser has collected a number of cases in which it would appear that patients with chest wounds were literally bled to death. It would be easy to augment the list, and to present, on the other hand, instances as numerous, in which patients survived enormous depletion; and the advocates of phlebotomy would reply, that the instances only proved that the former group of cases embraced those that seemed to demand excessive depletion, and were of such a character as would probably terminate fatally under any treatment, not that the remedy had worked any ill to the patients. It does not appear that the subject admits of solution by the numerical method. The statistics evoked in connection with Dr. Bennett’s extended therapeutic enquiry into the utility of venesection in pneu- monia, by no means proved that phlebotomy was always prejudicial in that disease; but simply that excessive bleedings in very old or young or slender persons were invariably harmful; while, of the largest series of cases collected on this subject," that in which the mortality was lowest, was taken from the army lists, for periods when moderate l)leeding was the prevailing practice. But the assumption that blood-letting, by withdrawing from the circulating medium its excess of flbrine, and other assumptions equally false, and all tending to the conclusion, that the greater part of the blood must be abstracted in order that the disease might be cured, — to bleeding as far as consistent to life, as Ballingall expressed it, — without limit, as John Bell taught, — led to the most reckless and injudicious treatment, in which the reaction of exhaustion was constantly mistaken for renewed inflammation, and met by repeated venesection. The reaction following the discovery of 1 Gross, a System of Surgery^ 5th cd., 1672, Vol, II, p. 447. 2 See the British and Foreign Med-Chir. llcciew^ Vot. XXIF, July, 1858. They arc collected from very varimiR sources, and their value in the author's own estimation is apparently not great ; for though he strictly analyses those that admit of it, he does not even sum up tlic figures which he gives as a whole. 82 650 WOUNDS AND INJURIES OE THE CHEST — CONCLUDED. [Chap. V, the fallacy of these assumptious led to such a state of feeling that a practitioner now hardly dares to use the lancet, whatever his views of its employment may be, and the advantages that might be secured by bleeding in injuries of the lung, in vigorous subjects, in the first day or two after the reception of the injury, and by the use of leeches and scarified cups in pleurisy and cardiac complications, are very rarely sought.^ In like manner, the want of confidence in the efficacy of mercurials in inflammation appears to have arisen from a growing conviction that their employment is based upon a false theory.® In the surgery of the blood-vessels of the chest, I conceive we may fairly look for improve- ment. It will not be claimed that all the fatal cases of lesions of the mammary, inter- costal, axillary, and subclavian arteries, that have been narrated in tliis chapter, were necessarily beyond the resources of art. It is surely possible to reduce the great disparity in the mortality of ligations for traumatic causes, as compared with the results of operations for aneurism. I rejoice to find myself so fully in accord with my friend. Dr. Lidell, on this subject; and heartily applaud his vigorous invectives against temporizatioU with compresses and styptics, when serious bleeding is going on. “Never be afraid to look your enemy in the face” is as good advice for the surgeon as for the soldier. * Consult Sir Thomas Watson’s Practice, of Physic., 5th London ed» ; Bennett, J. H., Clinical Lectures on the Principles and Practice of Medicine, 2d Am. ed , 1863, p. 648; BuYant, The Practice of Surgery, London, 1872, p. 152. * Dr. Baiiclay, Medical Errors, p. 119, says : “ The treatment of acute inflammations by calomel and opium, which was deduced from the supposed action of mercury as a solvent of fibrine, has not been very long introduced into practice. A few years ago experience would have been said to be universally in its favor, especially in the treatment of inflammation of serous membranes. Now, not a few of the most intelligent members of the profession discard it altogether, and a certain vague feeling of doubt as to its efllcacy more or less pervades all classes.” The following extract from remarks by Mr. Henry Smith, Medical Times, Nov. 23d, 1850, p. 234, should have appeared in the foot-notes to page 613 : ‘‘I found, after deatli, several ribs broken, and the lung severely lacerated by their broken and rugged extremities ; yet no bleeding from the mouth had occurred ; even if the patient lives for days and weeks, and the lung be severely wounded, there may be no hsemorrhage ; the absence of it was striking in a patient of Mr. Partridge, who had received a gunshot wound in his left side, and who lived nearly three weeks. The ordinary signs of pneumonia soon appeared, but there was no haemorrhage, and It was considered probable that the ball had only taken a superficial course. On post-mortem examination, however, it was found that the ball had traversed the substance of the lung, and the most intense inflammation had ensued, which caused the death of the patient. Sometimes emphysema — although, as a general rule, it follows an injury to the lung from a broken rib— will not be apparent ; if, with other symptoms, which are even somewhat dubious, this be present, it will set the question at rest. Haemorrhage, even although a most important sign, as regards the treatment which is to be pursued, is not conclusive of an injury to the lung ; nor, on the other hand, as has before been stated, does its absence clearly indicate that there is none.” INDEX OF REPORTERS Page. Abraham 293 Adolphus Adams 440 Adler 494 Agaud 461 Ainsworth 56 Akin 481 Albright 43 Alexander, C. T 56 Alexander, S. T 273 Alden 83, 92, 329, 348, 396, 567 Allen, H 86, 112, 160, 288, 351, 438, 487, 505, 529, 541, 568, 575, 587 Allen, B. W 107, 129, 244, 245, 246, 275, 287 Allen, L.H 190 Alle.n, N 222 Allen, J.L 330 ALSDORE 226 Ames, A. E 291, 479 Ames, A. H 491 Antisell J18, 367, 477, 483, 528, 550, 554 Anawalt 172 Ansell y. .255, 435 Anderson 285 Armsby 45 Arthur 167, 202, 437 Armstrong, J. E 240 Armstrong, J. A 520 Artaud 283, 363 Atwood 59 Atkinson 274, 417 Atwater Ill Atwater, H. H 430 Avery 330 Ayres 23,444,546 Ayer 290 Azpell 58, 538 Bailey 37, 45 Baily 220 BaCUE, D 38 Bache, T. H 40, 80, 163, 367 Barnum 39 Bacon, P., Jr 83, 276 Bacon, C 448 Bardin 119 Batwell 147, 209, 265, 412 Bald-win 161,277 Bates, E. F i08, 349 Bates, W. S 239 Bates, J 292, 479 Bard WELL 178, 226 Baxter 189, 274 Bartholf 198, 204, 237, 250, 330, 520 Bassett 239 Bartholow 458 Bartlett 487 Backus 487 Barr 502, 506 Bennett, John 42 Bennett, W. C 73 Bennett, E 193 Page. Bentley 44, 45, 53, 54, 58, 76, 86, 88, 133, 183, 184, 188, 201, 206, 248, 265, 268, 289, 302, 350, 351, 353, 354, 356, 360, 364, 365, 426, 436, 437, 441, 445, 450, 467, 473, 557, 628 Benedict 101,539 Beel 119 BELLOWS 150 Bell, James 178 Bell, John Bell, j. B Benson Beach Beck Belknap Beeser BEUST Becker Billings Bigelow, J. K Bigelow, h. J Bigelow, C. P Bing Bliss, D. W... 203 227 178, 208 213 218 289 291 432 547 60, 231, 292, 302 164 193 249 461 49, 59, 125, 143, 171, 238, 248, 266, 268, 269, 272, 278, 279, 281, 284, 296, 301, Bliss, Z. E . Blossom . . . Blackrurn Blackman . Blein Bontecou.. Bos worth Borbs Bowling BOWEN, W. H . . Bowen, C. 11..“ BOWEN, W Bowen, II. F . . . Bockee Boynton Bradley, W. A Bradley, W. H Bradley, E Breed Brown, E. O... Browne, P. F. . Brown, j. N . . . Brown, j. A . . . BROWN, J. II . . . Brown, F. H ... Brow.n, j. m... Brinton, r>. G . Bkinton, j. H.. Briggs Brumley Brillantowski 346, 349, 408, 412, 516, 583, 590 53, 217, 356 175 236 369 559 4, 20, 43, 82, 124, 148, 241, 250, 264, 346, 350, 355, 432, 438, 451, 456, 493, 528, 529, 530, 548, 551, 555, 578, 579 41 54 59 201 444, 584 461 221, 456 274 413 47 175,481 178,289 54, 73, 302, 526, 546, 573 54,78 78, 451, 503, 542 231 233, 419 238 540 618 183, 501 . . .58, 367, 401, 402,-515, 589, 628 59 78,501,506 92,200 Brewer Bradford, G. \V ... Bradford, F. G. H Breakby Brookes Brooks, E Brooks, O. D B rattan Brock Bruraker Bryant, H Breneman Page. 141, 461 177 216 178, 192, 505, 506 180 203, 246, 431 285 186 211 577 213, 490,562 254 Burke Buchanan Buckm.vn, j. W. . Bl'ch.\nan, W. F Butler, j. II Butler, T. S Butler, W. H . . . Buzzell Burpee Burmeister Burdick Burt Bundy BUCK, A. A Buck, G Buck, II. A Buckingham, A . BUELL 43,58 59 114 244 18 240 476 lOL 108, 159, 354, 364 139, 163 172,239, 013 229 234 354 .... 373, 375, 376 405 573 411 Byrne 74,75,143, 201, 273, 349, 35.5, 425, 435, 438 ■BYLES, C 635 Calhoun 39, 48, 77, 363, 367 Camac 41 Carter 92, 3.54 Cahoon 100 Carvallo 116, 441 Carell 126, 215, 300, 557 Canniff 129 Cake 134 Carson 187 Camprell, j 205 Camprell, C 229 Carroll, t 206 Carroll, R. W. W 418 Cass 249, 360 Cantwell 277, 420 Castle 410 Cameron 496 Carpe.nter 584 Ciiamrers 40, 458 Chapel 71 Chajirerlain, C. N 98, .501 CIIAMRERLAIN, -W. JI 234, 37], 409, 5.59 Cherronnier 105, dl9, 620 Christian 114 Chandler 134 Churchill 190, 237, 240 Chase, I. .S 236, 473 Chase, E. G 247 II INDEX OF KEPOKTERS, Page. Choate 2:!8 CmilST 275 ClIEEVEll 279 Chapin 5(iC Clahk, a. P 21 Clark, C. II 138 CLARK, C. C. P 174 Clark, E. A 211, 370 C;lauk, a. M 25], 503, 504 Clark, C. JI 293, 362 Cloak 41, 55 Clapp, A. M 48 Clapp, IV. a 355 Clkizer 196 Cleaver 208 ClEXDEXIN, W 229,303,524 Cr.EXDEMX, W. II 291 C'LIiJlEXTS 227 Day, W. E De.yn DeGraw Derby, A. R Derby, G . . - Devendouf . Devens Delay AN Page. 423 Ill, 205, 213, 248, 249, 252, 253, 273, 435, 480, 493, 556 534 85 71 180 232 488 Dickinson 75 Dieffexhach 177 Dickie 528 Dorr 274 Dodge 108 Draixe 38 Draper 301 Dunglison 227 Dunton 372 Cleary 393 Cooper 22 Colby 17 Conner 54. 181, 224, 249, 254, 30) , 327, 560 Collins 72 Cogswell 83 Cobb 84 Coventry 116 Cornell 119, 501 Coale 143 Coleman 164 COWGILL 164, 212 Cowles 175 t:oRLis 186 CONKLING 186,290 cook, G. W 238, 526 Cook, A. P 451 Colburn 240 Colvin 288 COJIBS 290 Conover 294, 473, 593 Cole 298 Coombs 393 COE 480 CROSBY', T. U 51,73,330 Crosby, a. H 445 CROSBY, H 588 CROYVE 57 CllOPP 119 DUSENBURY DUTTON Dudley Dwinelle Dyer Eastman Edyvards Edelin Edgar — Ellis, C. M Ellis, J. W Elliot Ellsyvorth, J. W Elrod Ella Ely Em.yxuel Emory Evans Eva RTS E.ylley, C. E F ALLEY', J. \V Fay, j. K Fay, j. YV Farquelle Farnsyvortii Farrar fercusson feris 426 433 ....488,489 181, 488, 489 462 132 33 266 270 494 .269, 274, 418, 574, 587 291, 495 292 397 577 209 445 183 501, 502, 506 105, 585 574 208 353 458 491 586 163, 192 186 Craig, YV. II 442, 488 CRAIG, 15. F 363,482 CRAWFORD 398 CUMMINSKEY 103, 130, 189, 215, 230, 403, .501 CURP.IiY 160 CUJIMINS 197 Cutter 294 CUTLER 239 CULBERTSON 369, 372, 378, 418 CURTIS, E 539 CURTIS, I. 15 573 Daggett 407 Dana :86 Dare 205 D.YVIES 419, 432 D.vvis, A 221 Davis, J 41 Davis, P. C 5.5, 406, 462 Daives 77 Day, n. 15 104, 120, 208,223, 237 Day, 15. j 288 FINLEY', C. A . FINLEY, S. M . FINN Fitch Fisher Fischer Fisk, C. L — Fisk, S. A Flandr.yu ... FOLSOJI Foye Foryvood Forbes Foster, F. 1’ Foster, T. A. Foisseit Fox FONTS Frantz French, .1. O French, G. F 22 59, 4.51 462 107 149 588 197, 240, 496 500 92, 174 46 55, 516 71 370 418 238, 458 128 242, 286 271 ,.50,54 232 .363,451 489 Page. Franklin 289, 292, 350, 452, 523 Frasse 356 Fuller, G. E Fuller, S. E Gallagher . . Gale Galloway . . Galloupe Gay Gaucelon... G.idd Gardner Germaine... Gesner 442 539 114, 179, 480,620 191, 192,366,397 239 242 277 302, 360 430 496, 550 334 290 Geiger Gibson Gill Gilroy Gouley Goldsmith, M Goldsmith, YV. YV. Goddard Goslin Good Goodman Gordon Graham Green, YY*^. 1^ . . ... Green, M. L Green, J. B Guee.ne, a. S Gray Gross Grube Griswold, C. D . . Griswold, l. D . . Greenleae Grove Griffith Grier Guilford 596 250 487 526 58 74 102 . 131, 435, 494, 535 211,254 J . 223 351, 408 461 37,347 56 179 484 5.59 85 130, 133, 236, 249, 291, 539 142 239 297 243 275, 373, 546 279 326,405 120 IIappersETT 40, 470 Hammer 42, 129, .369 Hartshorn 53 n.AYWOOD 76 Hayes ,54, 75, 76, 82, 88, 107, 177, 222, 229, 230, 231, 330, 347, 491, 558 Hammond, YV. A Ha.mmond, U. D . Hajimond, YV. E. Hand, D. YV Hand, A. F Hayhlton, E. H . Hamilton, C. A . Harding Hasbuouck Hanna Hay Hazen 58 188 200, 447, 521 74, 46'6 222 110,488, 517, 532 476 172, 194 178 183 188,433 197 Hart 219, 586 Hartsyvick - 233 Hazleton 239 Hall, A. D 364,574 Hall, J. A 559 IlACIlENBERC. 439 Harris 459 IlAMU.M 459 Hermann 17 INDEX OF REPODTEEP. Ill Patjo. Pkwit 35G, 5G6 HKICI1HOI.I) 31 HEARD ■ 33 Helshy 41, 338 Hesnixg, T. S 4C, 135, 339 Herbst 54, 304, 4G1 Heger 72 Herrick 78 HEXUT 129 Henson 174 HELM, J. C 225 Helm, W. H 468 Helmer 223, 330 Herndon 279 Hendricks, J. G 284 Hendricks, E. F 136, 556 Hewitson 348 Hendrickson 420 Herriman 554 Herron 501 Hickman, T. G 72 Hickman, N 80 Hildreth, G. D ■. 238,369 Hildreth, J. S 419 Hirshfield 413 Hill 553 Hilburn ; 482 Hitchcock 533 Higgins 483, 523 Homans 49, 54, 55 Homiston 43 Horton 37, 58 Hopkinson 81, 118, 130, 148, 199, 220, 271, 276, 277, 353, 476 Hodge 108, 230, 291, 327, 346 HOPl’IN 118 Hosack 163, 635 Hobbins ■■ 173 Horn 182 Houts 182,246 Howell 185 Hooper 223 Hogeboom 275 Howard. .282,497, 499, 500, 503, 504, 505, 517, 550 Horner 290 Hodgen 325, 485, 540 Holley 362 Hope 410 Horwitz 441 Hogan 462, 551 Hobart 463 Hoy 500 Hood 528 Hupp 31, 192 Hunt 53 Hubbard, S 56 Hubbard, H. B 229 Hubbard, V. B 550 Huron 60 Huber 533 Hurd, H. S 133 Hurd, J. S , 190 Huntington 173 Hubbell 215 Hutton 221 Hutchings 238 Hutchinson , 262 Hyde, J. N 367 Pane. Hyde, J. H 104,476 IMPEY 42 Ingram 37, 286, 292, 475, 529 IsilAM 42.470,573 Irwin 506 Janes 72, 350 JAMAR 265 Jackson 496 Jewell 105, 116, 295, 502 Jewett 480 Jessup 290 Johnson, H. B 234 Johnson, K. L 560 JONES 30 JONES, W. P 75 JONES, G. S . . .118, 119, 232, 242, 29J, 354, 409, 451 JONES, R. K 208, 232 JONES, W 1 214 Jones, C. W 299, 356, 359, 364, 590 JONES, J C 396 Jones, W. B 460 JUDSON 42, 87, 168, 184, 265, 272, 352, 378, 432, 439, 475, 483, 485, 548, 563, 564, 593 Kayes 405 Keating 348, 447 Kenderdine 38 Kendall 56 Kennedy, J. F 81 Kennedy, D 261 Kelly, F. \V 82 KELLY, E. B. P 281 Kern 106 Keen 115, 175, 176, 207, 370, 407, 430, 447, 475, 630 Keenon 45, 142, 216, 285, 419 Kellogg, A. H 173 Kellogg, G 176 Kemper 225 Kempster 273 Kenney 230 Kerr., 266 Kedzie 487 Kipp 32,146 Kitchen 33 King, J. S 58 lasG, C. B 354 King, J. E 104 KISHER 174 KILBURN 254 KIBBIE 232 Knowles 18 Kneeland 51, 59, 443, 502 Koehler 278 Kirker 442 Lawrence 238 Lambert 285 Lathrop 329 Langmaid 416 Legler 38, 151 Lewis, J. B 56, 133, 169, 211, 262 Lewis, R. S 230 Lewis, R. J 458 Leale 59,502,575 IjEsher 191 Leighton 201, 229 Levergood 239 LEAvrrr 248, 252, 556 Papje. LeConte 2.57 liESLIE 292 Leedom 331 Leidy 431, 569 Livesay’ 293 Lidell 40, 49, 110, 122, 161, 195, 203, 263, 204, 349, 446, 524, 543, 559 Lineaweaver 347, 499 LIEBOLD 416 LONGWILL 104, 482 Longenecker 132, 585 Looms 223, 232, 282, 410, 533 Logan 3.56 Lowell 388 Lord 582 LOUGHRAN .458, 577 Loughridge 499 Lockhart 533 Ludlow 37, 554 Lyman, J.B 129 Lyman, S. W 510 Lynn 191 Lyster 199 Lytle 529 MacDonald 116 Matlock, J. M 4 Matlock, W. H 569 Mackenzie 58 MANSON 77 Marshall 82 Maull 120 JIACE 550 Martin, O 176, 194, 238, 411, 461 Martin, H. A 269 May 201,208,449,574 Mahon 228 MaNSITELD 216, 328 MACKAY 290 Marsh 477 Maxwell 582 McKee, J. C 22, 77, 160, 199, 240, 244, 245, 251, 252, 284, 332, 349, 350, 353, 374, 490, 496, 536, 567, 569 MCKEE, J. G 346 MCKIBBIN 47 McAllister 55 McMahon 50, 60, 297, 347, 471, 574 McClellan. ... 71, 74, 80, 83, 87, 113, 287, 401, 541 McClelland 538 McDermont 75, 124, 225, 492 McParlin 76,81,352 McEWEN 83 McCall 8.5, 106, ill, 165, 195, 206, 280, 348, 474, 499, 500, 505, 554, 567 McCaw 102 McCook, G 117, 131, 216, 225, 226, 367, 405, 410, 411, 483 McIntosh 178, 196 McCann 179 MCNEILY, T. S 194,234 Mcknight 208, 480 McNulty 272 McLean 286 McGlaugulin 295 McArthur 320 McDonnell 350 McClure, a. r .353 McClure, A. W 460 INDEX OF REPOETEES IV Page. McFalls 309 MCNeilly, R 419 McQueston, C. a 452 McQueston, C. B 521 McReykolds 479 McKay 482, 497 McJilton 582 McMillen 526 McEldeuey 574 MEACHAM 36, 43, 470 Meagher 163, 359, 474, 590 MeaRS 102, 179, 292 Means 129 Metcalf 292 Merrill, A 368 Merrill, C. S 577 Mendenhall 408, 412 Mead 477 Miles, B. B 55, 109, 169, 300, 354, 361, 439, 444, 408, 5<:3 Miles, W. H — 408 Mitchell 106 Mintzer 116 Miller 416 Moseley 72, 70, 120, 171, 240, 247, 253, 254, 255, 260, 277, 298, 340, 349, 359, 300, 393, 540 Mott 70, 105, 401 Moon 104, 225, 207, 275, 295, 302 Morrison 211 Morris, T. C 228 Morris, J 484 Morgan, D 270 Morgan, W. P 347 Morton 277, 378, 413, 555 Moody 416 MOSES 73, 144, 202, 274, 393, 551, 630 Morehouse 124 Montgomery 103, 243, 378 Mullen 146, 449 MURSICK 200, 247, 248, 250, 254, 353, 366, 440, 459, 502 Muliiallen 490 MUNN 504 MYGATT 462 Nagle 489 Newell 18 Nelson, J. C 121, 3.50 Nelson, A. W 582 Neff 162 Neill 108,177, 182,197, 236, 280, 357, 358, 300, 304, 474, 520 Neil 171, 223,232,480 Neilson 479 NIGLAS 142 Nichols 223, 280 Nicholson 502 Notson 34 NORVAL 42, 78 NORRIS, J. W. S 197 NORRIS, W. P 417, 418, 492, 508 Norris, A. L 433 Norris, J 545 Nordman 372 North 493 Nye 230 Oakley 191, 582 O'Brien 403 ( I’CciNNIil.1 330 Page. Oliver 493 O’Keefe 210, 245, 270, 281, 491 Orton, S. II 72,438 Orton, j. G 102, 106, 234, 308 OrMSRY 204 Otis, D. A 233 Orro 224 Otterson 368 OWEN, G. S 183 OWEN, D. C 190 Owens 237, 484 OWINGS 409, 442 Paullin 21 Palmer, J. C 558 Palmer, E 34 Palmer, G. S 41, 185 Palmer, T. M 79,120 Palmer, II 133, 215, 286, 340, 350, 456, 523 Pancoast 41, 82, 217, 297, 353, 304, 390, 443, 407, 539 Page, C. G 42 Page, C 202,499 Page, W. H 240 Patten 117 PARiiER, \V. S 102 Parker, F. S 179,245,295 Paine 174 Packard 358 Parke 352 Peters 44, 113, 122, 165, 196, 416, 407, 492, 549 Peter, P 197 Peter, R 470 Pe.abody 72 Pettinos 202 PERRY, D. O 238 Perry, 1 4il Perin 287 Peck 369, 419 Perdue 477 Pfoutz 117 PH ELI'S, S 372 Phelps, a. j 77 Phillips, John 129 Phillips, James 446 Phillips, J. H 527 Phillips, H. J 554 Pitts, J. C 104, 283 PierpONT 237 Pierce 238 I’kjuette 470 Pick 589 PINEO 636 Plumb 269 Pl.ant 583 Powers, E. M 37, 351 Powers, C 88 Pope 78 Porter, G. L 171, 440 PORTER, P.C 188 Porter, C 224,327 Porter, F. S 235, 469 Porter, I. G 578 PO.MEROY 194 Powell 241, 558 Post, John 209 Post, L 241 Potter, W. W 331, .529 Potter, 11. A 357 PRAI.1 109 Page. Prince 269 Price 296 Purdy Ill Putnam 280 Quick 205, 233, 305, 480, 481, 564, 589 Rankin, S 50 Rankin, A. C 471 Ramsey 291, 409 Rahter 329, 451 Read, J. B 54, 98, 99 Reed, T. B. .72, 76, 116, 173, 215, 279, 458, 539, 555 Reed, Z 103 Redeb, C. T 73 Reuer, N. B 348 Reeder 284 REAMY 396 Reynolds 420 Reyburn 436 Reese 541 Rhodes • 120 Rice, N. P 48 RICE, C. D 74,78,214 Rice, P. B 226 Rich 78 Rivers 225 Rims 228 Richardson 406 Rigeu 470 Rockwell 49 Robie 57 Robbins 132, 239 Robinson 163 Roberts, J 171 Roberts, James 436 Roberts, W. E 414 Rowland, j. R 188 Rowland, Charles 20, 179, 239, 404, 478, 489, 490 ROEMER 279, 282 Ropes 370 Robertson 481 Romig 515 Rulison 17 Rust 19 RUSH ?. 77 RUBACH 237 Russell, J 290 Russell, E 461 Salter 73, 77, 408 Sanger 117, 501 Sanders 125 Sanborn 177 Sargent, G. P — 262 Sargent, W 462 Sapp, S. C 293 Sapp. E 496 Sawtelle 352, 410, 401, 424 SafforD 359 Sands 370 Schell 38, 112, 129, 182, 193, 226, 471 Schultz 40 Schafhirt 57 Scholl 187 ScoviLL 237 SCARFF 474 Seyffarth 33,567 Searle 136, 197 SelDEN .543 Sheldon 41, 74, 82, 80, 289, .540 INDEX OF REPORTERS, V Page. SllAKP 108 SllUMAHD 139 SliERMAX, S. N 141, 1S8, 230, 555 Shekievk, a. M 393 Sherman, B. S 515 Shurlock 243, 270 Sheets 251 SHirM.^N 2C9 Shedd 584 SlILMEU 437, 447 SURADY 539, 502 SUI 19, 54, 436 Simons 87 SIMINGTON 100, 034 SILUM.VN 113 SlvlLLERN 444 Smith, E. H 33,129 Smith, S. B 50 Smith, J. S 50,92 Sjiith, E. S 54 Smith, J. R 55, 81 S.MITH, J. B 73 Smith, G. M 75 Smith, G. K 81, 618 SlUTH, E. A 100, 104, 258, 289, 356 SSHTH, T. F L16 Smith, D. P 125,266,268 Smith, J. O 201 Smith, A. G 272 Smith, J. W 373 Smith, A. A 485,522 S-MITH, L. a 487 Smith, T. B 585 Smith, A. H 631 Smith, L 634 .Smyser 113, 134 Smiley 133, 213, 271, 331 Small 442 SmULL 205,437 Smart 509 Snow 238 Spencer 74, 83, 552 Spaldlng, j. W 133, 238 Spalding, P 224 Sprague 331 Squire 210, 407, 553 Stuckslager 50 Stahl 51 STORROW 73, 264, 351, 522 Stearns, II. P 79, 122, 355, 466 Stearnes, j. G 98, 187 Sterling 134, 589 Stickney 173 STANFORD 202 Stewart, J. L 224 Stewart, P 279 Stewart, W. D 585 Stii.lwkll 204, 297 Sttuckler 228 Stone, B 233 Stone, L. R 461 Stratton 230 Strickland 240, 563 Stevens 24o Streeter 278 Study 28.5, 470 Stanway 289 Sta.nchfield 330 Page. Stanton, D 301 Stanton, j. O 407, 585 Stonelake 564 Sturgis 419 Stichley 579 SUCKLEY 38,237,504 Sutton 88 Summers 331, 302, 499 Swift 117, 171,226,515 SWARTS 1S4 Swesserott 281 Sweet 300 SWARTZWELDER 477 Taylor, R. R 38 Taylor, G 72 Taylor, J. II 72, 88, 145 Taylor, L 72, 74, 115, 350 Taylor, M. K 218 Taylor, J. S 416 Taliaferro 50, 55, 105, 100 TEED 102 Terry 198 Tiirelkeld 39,84 Thom 76, 597 Thayer 113 Thompson, J. W 233 Thompson, E. A 130 TIIOJIPSON, J. H 219 Thomson 123, 181, 207, , 297, 351, 354, 361, 392, 405, 421, 436, 440, 444, 440, 447, 400, 487, 527, 572, 573, 576, 578, 579, 583, .589 Thorne 125 Thorn 221 Thomas, II. L 456, 538, 540 THOJIAS, W. B 22.5, 494 Thorpe 460 Thomain 515 Tuts 228 Tice 283 Todd, J. M 209, 228 Todd, C. II 420 Toward 290,370,490 TOWNSEND 540 Trull 79,87 Trenor, j. B 102 TRENOR, J 242 Treadwell 103, 238 Tryon, a. W 251,290 Tryon, j. R 558 Trowbridge 287, 330 Treganowan 500 Tuit 147, IGl TURNER 286 Turney 289 Udell 192 UPILYM, J. B 124, 184, 347 UPHAm, G. B 550 VANDERKIEFT 57, 71, 121, 170, 355, 432 Varian, W 114, 117, 559 Vanderveer 131, 102 Vanderiiuli 180 Van Duyn 193 Van Slyck 510 Valk 393 VENABLE 58 VOSBURGII 149 Van Tagen 507 Page. Wardner 19, 41, 102, 108, 208, 410, 523 Ward, W. F 39,135 Ward, S. B 58 IVaTSON, a. T 57 Watson, R. R 499 Waters, E. G 103,574 Waterman 131 Wagner, F.B 189 Wagner, C 267, 300, 407, 588 Wagenseller 191 Walker 241 Wakefield 305 Walsh 459 Watkins, A. P 585 Webster 18, 74, 214, 269, 352, 5.55 Weir 21, 142, 235, 299, 303, 355, 300, 377, 417, 420, 431, 450, 531, 559 Wells -54 WELLFORD 73, 125 WESTON 117,225 WetmorE 232, 282 WELCH 458 White, J. A 40 White, J. 1 108 White, H. B 271 Whitehill 174 Wheeler 231 WllISERY 285 WHITING 351 Williams, J. W 17,214 Williams, P 174 Withers 53 Wilder, a. M 82,200, 204,212 Wilder, B. G 302, 427, 445, 533, 553 Wiley 88 WILLEY 217, 289 Willard, S. D 134, 185,288 Willard, J • 276 WILLARD, A 401 WILSON, B. B 123 Wilson, J. F 193, 471, 531 WILSON, J. R 239 WILSON, M. W 520 Wilson, Albert 582 WILCOXSON 268 Win ANTS 320 Winslow 421 WILLIS 462 WIRTII 582 Woodward, A. T 53 Woodward, j. j 77 Woodward, B 210 Woodworth 77, 79 WOLVERTON 79 WOODIIULL 131, 285 WOLFE 214 WOOD 221, 233, 242, 275 WOODS .>. 501 WOODRITF 300 Wright 137 WYNKOOP 138, 187,480 YVyman 231 Yates 34 YaUGAN 97 Yandell 272 Young 105, 235 Younglove 430 ZeaRING 527 . ■ /■ / v I \ V V f I f jf - 0 s: * 17 -• ^ . 1^’ • \ ■■ I i I 1 ( \ pK i >; »} \ * ‘S* ,1 ■if.